From the Editor

Stimulants are commonly prescribed to children with ADHD. Do they protect kids against future substance misuse? Or, having been exposed early to stimulants, are these patients more likely to develop substance problems in adulthood?

Past studies have attempted to answer these questions but have been limited by study design. In a new JAMA Psychiatry paper, Brooke S. G. Molina (of the University of Pittsburgh) and her co-authors take a fresh look. In a cohort study involving 547 students, some of whom were treated with stimulants while others received behavioural therapy during the first period, Molina et al. look at outcomes when these participants are in their mid 20s. “This study found no evidence that stimulant treatment was associated with increased or decreased risk for later frequent use of alcohol, marijuana, cigarette smoking, or other substances used for adolescents and young adults with childhood ADHD.” We consider the study and its implications.

In the second selection, Dr. Juveria Zaheer (of the University of Toronto) discusses patient suicide in a new Quick Takes podcast interview. Focusing on the impact on psychiatrists and residents of psychiatry, she draws from the literature, including a study she recently senior authored for The Canadian Journal of Psychiatry. She notes common reactions by psychiatrists and residents, including guilt and shock. And Dr. Zaheer talks about her own experience. “I’ll never forget when it happened.” 

And in the third selection, Lucy Foulkes (of the University of Oxford) writes about anxiety and current approaches. In a Guardian essay, she notes her own history as an “anxious teen” and wonders if life is better for today’s adolescents, with awareness campaigns but not necessarily meaningful services. “We are now in a situation where many teens know or believe they are anxious but aren’t getting the help they need to manage it.”

The Reading of the Week has formal partnerships with 14 postgraduate programs and, today, we welcome PGY1s who are joining us from across Canada.


Selection 1: “Association Between Stimulant Treatment and Substance Use Through Adolescence Into Early Adulthood”

Brooke S. G. Molina, Traci M. Kennedy, Andrea L. Howard, et al.

JAMA Psychiatry, 5 July 2023  Online First

Childhood attention-deficit/hyperactivity disorder (ADHD) carries risk for elevated substance use and substance use disorder (SUD) by adulthood. Stimulant medications, a first-line treatment for ADHD, should decrease substance use given the prominence of impulsivity in models of addiction and the acute efficacy of stimulants for ADHD symptoms, including impulsivity. However, early exposure to stimulants may cause neurobiological and behavioral sensitization to other drugs and thus increase the risk for harmful substance use. A 2013 meta-analysis found no associations consistent with either protective or adverse effects of stimulants on substance use or SUD. After further individual studies with mixed results, a 2014 meta-analysis supported protective associations for cigarette smoking…

Age confounds the stimulant–substance use association. As substance use escalates through adolescence, well before most SUD diagnoses, adolescents with ADHD are increasingly unlikely to continue taking prescribed stimulants. Thus, without adjustment for age, associations between stimulant medication and substance use may be spurious. Groenman and colleagues found no differences in adolescent daily smoking across age-matched stimulant treatment profiles. A further complication is that some adolescents resume stimulant medication after months or years…

Other factors driving both stimulant treatment and substance use are numerous, including sociodemographics, symptom severity, psychiatric comorbidities, functional impairment, psychosocial treatment and factors affecting it (eg, insurance), and parent characteristics (psychopathology, parenting practices/attitudes).

So begins a paper by Molina et al.

Here’s what they did:

“[Multimodal Treatment Study of ADHD] was a multisite study initiated at 6 sites in the US and 1 in Canada as a 14-month randomized clinical trial of medication and behavior therapy for ADHD but transitioned to a longitudinal observational study. Participants were recruited between 1994 and 1996. Multi-informant assessments included comprehensively assessed demographic, clinical (including substance use), and treatment (including stimulant treatment) variables. Children aged 7 to 9 years with rigorously diagnosed DSM-IV combined-type ADHD were repeatedly assessed until a mean age of 25 years.”

Here’s what they found:

  • 547 children were randomized.
  • Demographics. The mean age was 8.5 years and 80% were male. In terms of ethnicity and race: “A total of 115 participants (20%) were African American; 48 (8%), Hispanic; and 351 (61%), White.”
  • Substance use. “Substance use increased steadily through adolescence and remained stable through early adulthood. Mean percentages across the 12-, 14-, and 16-year follow-up assessments were 36.5% for daily smoking, 29.6% for marijuana use at least weekly, 21.1% for heavy drinking at least weekly, and 6.2% for other substance use at least monthly.” See figure below.
  • Stimulants. “The share of adolescents using stimulant medication declined precipitously through adolescence from nearly 60% at the 2- and 3-year assessments to 7.2% on average in early adulthood.”
  • Models. “Generalized multilevel linear models showed no evidence that current… or prior stimulant treatment… or their interaction… were associated with substance use after adjusting for developmental trends in substance use and age.” Further: “Marginal structural models adjusting for dynamic confounding by demographic, clinical, and familial factors revealed no evidence that more years of stimulant treatment… or continuous, uninterrupted stimulant treatment… were associated with adulthood substance use.”

A few thoughts:

1. This is a good study with much to like: an RCT design with multiple sites involved and featuring an impressively long follow-up period. The journal is a big one, of course.

2. The above summary is simple and some of the nuance and detail of the study aren’t described. Note, for example, the multiple assessments done over years: “Participants were assessed at baseline prior to randomization, at 3 and 9 months, at conclusion of the 14-month treatment, and at 2, 3, 6, 8, 10, 12, 14, and 16 years after baseline.” But were many participants lost to follow up? “95% were reassessed at least once between the 2- and 16-year assessments.” (!)

3. The results in a sentence: “our 16-year prospective, comprehensive, and developmentally sensitive analyses of stimulant medication associations with substance use failed to support any hypotheses of substance use protection or harm from stimulant treatment for ADHD.”

4. In other words, both proponents and critics of these medications will be disappointed since prescribed stimulants didn’t decrease or increase risk of substance problems.

5. Like all studies, there are limitations. The authors note several including: “we lacked medical records to verify medication history, although confidence in our data is supported by studies showing concordance between parent report and medical records.”

6. The decision to start a young patient on any medications is complicated, and needs to be considered in terms of risk and benefits. There are good and evidenced reasons for a stimulant trial, but this study suggests that concerns about future substance misuse aren’t among them.

The full JAMA Psychiatry paper can be found here:

Selection 2: “Patient suicide and its impact on residents and psychiatrists”

Juveria Zaheer

Quick Takes, July 2023

Up to 80% of psychiatrists experience a patient suicide in their careers yet a recent study finds that the majority feel caught off guard by the emotional impact. In a Quick Takes interview with Dr. Juveria Zaheer, a psychiatrist and medical head of the CAMH ED, we explore this difficult subject, and attempt to answer some important questions: What are common reactions? Should a psychiatrist attend the funeral? What can institutions do to better support providers?  

Highlights from the discussion:

On reacting to loss

“The big [emotions] are grief and sadness – this idea that they are really disturbed by the loss, that they lost someone who was a human being with unique qualities, and they built a relationship with that person.

“Another emotion is shock. You don’t expect to hear it, you don’t expect to get this call. And I know we try to talk about high risk and low risk, but it’s always surprising and it’s always a terrible shock when something like this happens.”

On medical culture

“As physicians, we think of ourselves as leaders. So, if I express my sadness and distress, who’s going to support the nursing team and the social work team? Who’s going to support the family? A lot of medical training is taking us away from those emotional pieces to say that we need to be strong, and we often do, and at the same time, both things can be true and our feelings and our responses matter.”

On supporting colleagues

“One of the most helpful things is talking to a colleague. Closing the door and sitting in a safe place and saying, ‘I went through this too.’ And I’m quite forthcoming with residents and with my colleagues about the loss that I had and how I reacted to it, because it gives them a safe place to comment on what’s going on. And easier to talk to another psychiatrist or mental health care provider about this than it is anybody else, even if they’re in health care, because it’s a very specific kind of grief and loss.”

On what administrators should do differently

“Less protocol. More connection.”

The above answers have been edited for length.

Dr. Zaheer’s Canadian Journal of Psychiatry paper can be found here:

The Quick Takes podcast can be found here, and is just over 25 minutes long:—patient-suicide-and-its-impact-on-residents-and-psychiatrists-with-dr-juveria-zaheer

Selection 3: “I’m a psychologist with a history of anxiety. Treating it as a permanent problem might make young people feel worse”

Lucy Foulkes

The Guardian, 9 July 2023

I was an anxious teenager. For me, the issue was always worry: excessive, awful, irrational thoughts that started when I was about 10 and reached their crescendo when I was an undergraduate, when things fell apart entirely and I needed a lot of treatment to be able to function again. Before I got help, I had no language to describe how I felt and no adults around me who understood what was happening.

As the public conversation about anxiety continues to swell, I’ve been asking myself: would I have been better off as an anxious teenager today?Despite all the recent awareness-raising efforts, the reduction in stigma, the lessons in schools – and despite how hard it was navigating my own anxiety in silence – I find myself answering ‘no’.

So begins an essay by Foulkes.

She notes the lack of understanding of mental disorders in the past. “I didn’t even know the word ‘anxiety’ until I was about 20. If my parents and my school had understood what was happening, my life could have been very different.”

She wonders about access to care. “But growing up now would only be better if it meant access to support, and I’m not sure most teenagers have that.” She notes the interest in mental health hasn’t translated into meaningful support for many. “Awareness-raising efforts in schools, online and elsewhere have flooded teenagers’ minds with the concept of anxiety, but funding for services has not caught up, and light-touch school interventions often aren’t enough.”

She also worries about the approach that we are collectively taking. “[T]here has been a huge increase in the number of young people who ask not to do things because they are anxious – and these requests are being granted.” In speaking to teachers, she explains: “Extensions to assessment deadlines are granted freely. One teacher said that there are so many teenagers who want to sit exams away from their peers that they have run out of rooms to accommodate them. A clinical psychologist working in schools told me that these adjustments are often put in place with no intention to review them, ever, as though the young person’s anxiety will unquestioningly be there – and should be accommodated – for ever, rather than being treated.”

She acknowledges that some may need “permanent adjustments” – for example, with someone who had been badly bullied and is fearful of school. “But in many other cases, automatic adjustments make things worse, because they rob young people of a vital opportunity.”

She favours that we find “a balance with how we manage anxiety in teenagers today.”

“Yes, give them the language they need and encourage them to talk about how they feel. Fund one-to-one therapy and make it accessible as soon as possible. Teach adults what anxiety looks like in young people and tell them how they can help. But as much as possible, avoid treating anxiety as if it is a permanent personality trait. And where possible, treat adjustments and avoidance as temporary measures, in the service of gradually helping young people tolerate and face their fears.”

A few thoughts:

1. This is a well-written essay.

2. She asks a big question: are adolescents with anxiety any better off today than in her youth? We have greater awareness, yes, but for many, we don’t have better public services. (She writes as a UK psychologist, commenting on UK services – but the comment seems also relevant on this side of the Atlantic.)

3. Is the current approach to accommodations problematic because, as Foulkes argues, it leads to the view that anxiety is a “permanent personality trait?” Readers can draw their own conclusions.

4. And, speaking of our current approach, some government officials now promote initiatives like mindfulness for students. In New York City, for example, high school students will be required to do mindful breathing for a few minutes daily, starting this fall. Are these efforts an important step towards better mental health or simply good PR when the harder work of helping those with anxiety problems isn’t being done? (NYC actually cut funding for anxiety-related programming.)

The full Guardian essay can be found here:

Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.