Droga para hiperativos tem uso banalizado

Especialistas atribuem explosão de vendas à dificuldade de diagnóstico aliada à impaciência de pais e professores

08 de agosto de 2010 | 0h 00

Karina Toledo e Mariana Mandelli, Sergio Neves – O Estado de S.Paulo

O medicamento usado no tratamento do Transtorno de Déficit de Atenção com Hiperatividade (TDAH) – vendido no País como Ritalina (Novartis) e Concerta (Jassen-Cilag) – está entre as substâncias controladas mais consumidas no País. Entre 2000 e 2008, o número de caixas vendidas passou de 71 mil para 1,147 milhão – aumento de 1.616%. A alta no consumo veio acompanhada de questionamentos sobre a banalização do uso do remédio à base de metilfenidato entre crianças e adolescentes.

Alguns especialistas apontam a demanda reprimida por tratamento que existia e ainda existe no Brasil como uma explicação para o inchaço nas vendas. Para outros, o fenômeno seria resultado de diagnósticos malfeitos, e crianças que simplesmente não se encaixam no padrão de aprendizagem e comportamento estariam sendo “domadas” à base de psicotrópicos.

O que alimenta ainda mais a polêmica é a dificuldade de diagnosticar o TDAH. Não há um exame definitivo. Os médicos se baseiam em relatos subjetivos de pais e professores sobre o comportamento da criança e num questionário com 18 sintomas relativamente comuns entre jovens, como falar em demasia, interromper conversas e dificuldade para esperar.

“O diagnóstico deve ser feito por um médico treinado, mas envolve também outros especialistas, como psicólogo, psicomotricista e fonoaudiólogo. É preciso descartar outros problemas de saúde que possam afetar o comportamento e o aprendizado”, explica o psiquiatra infantil Francisco Assumpção, da Universidade de São Paulo (USP). “Mas muitas vezes os critérios são preenchidos pela própria escola ou até mesmo pelos pais, que me procuram apenas para pedir o remédio. Ora, não sou fábrica de receita.”

Nem todo médico é tão rigoroso. O analista legislativo Luís Fernando Leite dos Santos conta que sua filha de 16 anos foi recentemente diagnosticada como portadora de TDAH por ter apresentado alterações de humor e queda de rendimento no último bimestre escolar. “A mãe procurou um neurologista já convencida do problema. Embora o relatório da escola afirmasse que o nível de dispersão nas aulas não era tão relevante, o médico receitou o remédio e ainda disse que eu poderia pegá-lo no posto de saúde”, diz o pai, inconformado. “Uma adolescente que está namorando pela primeira vez tem todos os motivos para estar avoada. Mas a mãe não admite que ela repita de ano.”

No caso do garoto João Petrika, de 12 anos, a simples mudança de escola fez milagres. Há cerca de quatro anos ele foi diagnosticado como hiperativo e ingressou num programa de tratamento da Universidade Federal de São Paulo (Unifesp). Fez terapia e tomou remédios. Mas o desempenho escolar só melhorou neste ano. “Antes ele fazia de tudo para evitar a escola. Agora que mudou de colégio, tem apenas três faltas”, conta o pai Antonio Petrika, segundo o qual o tratamento na Unifesp ajudou muito. Mas João, há dois anos sem remédios, tem outra explicação para a mudança de comportamento. “Gosto mais desta escola porque os professores são melhores. Na anterior, ficavam gritando o tempo todo. Eu ficava nervoso e não queria fazer mais nada.”

Na moda

O TDAH é um dos transtornos mentais mais comuns em crianças e se caracteriza por sintomas de desatenção, inquietude e impulsividade. Estudos indicam que a prevalência na população é de 5%. Isso significa que numa sala de aula com 40 alunos, pelo menos 2 teriam a doença.

Mas em algumas escolas o número de alunos em tratamento é bem maior que o estimado (mais informações nesta página). “A dificuldade de aprendizado passou a ser sinônimo de problema com a criança, quando às vezes o problema é da escola”, afirma Assumpção. Escola ruim, continua, não é só aquela que não ensina direito, mas também aquela que não respeita o ritmo biológico de cada criança. “Exigir que se aprenda a escrever com 4 anos, por exemplo, é um absurdo”, diz o médico.

Para o chefe da psiquiatria infantil da Santa Casa do Rio, Fábio Barbirato, os excessos existem, mas estão restritos às grandes metrópoles. “Nos locais mais pobres do País ainda há muita criança com TDAH sem tratamento”, diz.
A ideia de que os jovens estão sendo supermedicados, afirma Guilherme Polanczyk, psiquiatra especialista em infância e adolescência e professor da USP, está baseada numa parcela pequena da população. “Você percebe o aumento do consumo nas classes mais ricas, que têm mais acesso a tratamento.”

Tanto Barbirato como Polanczyk defendem os medicamentos à base de metilfenidato como primeira escolha de tratamento para TDAH. “Psicoterapia ajuda, mas controlar os impulsos e focar a atenção só se consegue com remédios”, diz Polanczyk.

Ambos também concordam que a falta de tratamento pode deixar o doente mais sujeito a comportamentos de risco, como usar drogas, dirigir de forma imprudente e se envolver em brigas.

“Não podemos demonizar o remédio”, afirma Iane Kestelman, presidente da Associação Brasileira do Déficit de Atenção (ABDA). “Quando se tem mais acesso à informação sobre a doença, é natural que se aumente o uso da medicação. Mas essa conta não deve ser paga pelo portador de TDAH.”

EVIDÊNCIAS CIENTÍFICAS

Causas
A genética tem papel fundamental, mas fatores ambientais como fumo na gestação e baixo peso no nascimento podem estar envolvidos.

Três perfis
Há o tipo predominantemente hiperativo, outro principalmente desatento e um terceiro tipo combinado.

Gênero
O transtorno é três vezes mais comum em meninos, mas o tipo desatento é mais frequente nas meninas

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What’s really behind the rising number of ADHD diagnoses among children and adults? Is it a reflection of pressure from pharmaceutical companies, or simply a way for parents to shirk their responsibilities? Read the theories.

By Lesley Alderman

Medically reviewed by Kevin O. Hwang, MD, MPH

You probably know at least one child who has been diagnosed with ADHD — attention deficit hyperactivity disorder. You might even know a few adults who believe they have the condition. ADHD seems to be everywhere: among our children, among our peers, and in the headlines constantly.

About 4.5 million, or 7 percent, of American children have been diagnosed with ADHD; diagnoses have increased by an average of 3 percent per year over the last decade, according to the Centers for Disease Control and Prevention. ADHD is now one of the most commonly diagnosed mental ailments among children and adolescents, and researchers estimate that 4 percent of adults have it too.

Given the rise in ADHD diagnoses, it’s not surprising that sales of the medications used to treat ADHD have nearly doubled over the past five years, from $3 billion in 2005 to $5.9 billion in 2009, according to IMS Health, a health care information and consulting company.

Is ADHD just a fad, the disease du jour of a society accustomed to medicating itself for every conceivable symptom? Or is it a serious condition that, like depression, is just beginning to be well understood?

Defining ADHD

To make sense of the numbers, it helps to understand the disorder itself. ADHD, when properly diagnosed, is not just an inability to focus and sit still, though those are two of the most common symptoms. “ADHD is a complex mental disorder that affects a person’s ability to regulate cognition and emotions,” says Stephen V. Faraone, PhD, a professor of psychiatry at SUNY Upstate Medical University who has been studying ADHD for two decades.

Those who have the disorder have difficulty coping with complex environments and following tasks through to completion. Because of these symptoms, “people with ADHD are at increased risk of academic failure, substance abuse, depression, divorce, driving accidents, and other negative outcomes,” notes Guilherme V. Polanczyk, PhD, an assistant professor of child and adolescent psychiatry at the University of São Paulo Medical School and an expert on ADHD. “People don’t understand how debilitating ADHD can be,” adds Dr. Faraone.

ADHD was first recognized as a mental disorder in the early 1980s, but researchers say the syndrome had been seen and noted much earlier. “It didn’t just appear magically,” says Ronald C. Kessler, PhD, a professor of health care policy at Harvard Medical School.

Then what brought the disorder to national attention? “Maybe it wasn’t a big deal decades ago,” Dr. Kessler theorizes. “As society becomes more complicated, the deficits that come with ADHD become more obvious. We place a premium on being able to get things done.”

Scientists also know a lot more about mental illnesses. “Child psychiatry as a discipline is a recent phenomenon, dating from the last half of the 20th century,” says Dr. Polanczyk. “Mental disorders in general — such as bipolar, including in children— have been increasingly identified because we know more about these conditions.”

Skeptics, though, worry that the label of ADHD provided a way for parents and others to shirk responsibility. “ADHD became a popular diagnosis in the 1980s as more parents went to work and the role of schools and teachers changed,” wrote Stephen R. Herr, EdD, in an online opinion piece in the Christian Science Monitor in August 2010. Dr. Herr, an assistant professor at Murray State University, went on to say: “The creation of ADHD as a psychological disorder was in part an attempt to deal with some of the difficulties of raising children. Unfortunately, that attempt has fallen short.”

Is ADHD an American Fad?

The diagnosis of ADHD has become increasingly common in the United States — but experts say this condition is widespread in rest of the world too. Find out why.

Once ADHD was defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM), the guide to psychological disorders published by the American Psychiatric Association, diagnoses began to rise steadily. Stimulants such as Ritalin and Adderall turned out to be effective at ameliorating the symptoms of ADHD, particularly problems involving focus and hyperactivity, at least in the short term, and drug companies began to vigorously market these medications.

But it wasn’t just U.S. doctors and clinicians who were beginning to recognize ADHD. At the same time ADHD was classified in the United States, it was defined in the World Health Organization’s counterpart to the DSM — the International Statistical Classification of Diseases and Related Health Problems (ICD). WHO’s definition was a bit more restrictive, though, so the rates of ADHD in the rest of the world seemed lower at first than the rates in the United States, says Faraone, adding that “the two definitions are becoming much more similar now.”

ADHD: Not a Simple Diagnosis

One of the problems in assessing the prevalence of ADHD is that there is no simple test to diagnose the disorder. The DSM instructs physicians to look for symptoms of hyperactivity and inattention that have persisted for at least six months and that interfere with a child’s ability to function in at least two areas of life, such as school and home. But the symptoms, such as “often talks excessively” and “often fidgets with hands or feet or squirms in seat when sitting still is expected,” sound an awful lot like the normal behavior of a child. It requires a skilled diagnostician to determine whether a child’s symptoms are causing real impairment.

Though teachers cannot make a diagnosis of ADHD, they can and do make recommendations about whether a child should be evaluated by a professional. A recent study from Michigan State University found that children born in the month prior to the cutoff date for kindergarten eligibility (i.e. typically the youngest and therefore most immature children within a grade) were far more likely to be diagnosed with ADHD compared to children born in the month immediately afterward. Therefore, some ADHD diagnoses may be “driven by teachers’ perceptions of poor behavior among the youngest children in a classroom” rather than true ADHD symptoms. Similar studies have fueled a suspicion among the public that ADHD is too frequently diagnosed and is diagnosed in a highly subjective manner. However, says Polanczyk, “The media approach misdiagnosis as if it is evidence that ADHD is not a valid disorder, which is absurd.”

And while most researchers believe that the disorder has a genetic component, they acknowledge that the context in which a child lives and goes to school may also contribute to ADHD symptoms. A 2005 WHO report on mental health, for instance, noted that the “diagnosis can be symptomatic of family dysfunction, rather than individual psychopathology, and may re?ect inadequacies in the educational system.”

ADHD: Not Just an American Problem

In recent years, researchers have tried to understand the prevalence of ADHD across the globe. A number of papers have examined studies in different countries and found that when the same diagnostic criteria and research methods are used, the prevalence of the disorder is fairly consistent across cultures. Polanczyk and his colleagues, for example, considered more than 100 studies from around the world and found that prevalence of ADHD was influenced more by the methods of the individual studies than by geographic location. “Wherever people have looked for the disorder, they have found it,” says Faraone.

There is some variation, though, in overall estimates of ADHD. Polanczyk’s study, published in the June 2007 issue of the American Journal of Psychiatry, estimated that the worldwide prevalence of ADHD is 5.3 percent among children and adolescents. Faraone, who coauthored a study published in World Psychiatry in 2003 that examined the worldwide prevalence of ADHD, believes that the incidence may range between 8 percent and 12 percent.

ADHD: Not Just a Childhood Problem

ADHD — once believed to be a childhood disorder — seems to persist into adulthood in about two-thirds of cases. Kessler of Harvard Medical School conducted a study using national household survey data in the United States and found that 4.4 percent of adults met the criteria for ADHD. “It’s a real thing with adults,” he says. The study, which was published in 2006 in the American Journal of Psychiatry, found that adults who reported having had ADHD symptoms since childhood had other emotional problems too. Many of these adults were not receiving any treatment.

In another study coauthored by Kessler, and published in Occupational and Environmental Medicine, the researchers found that adults with ADHD worked 22 fewer days per year than their co-workers without the condition.

Is ADHD Overdiagnosed?

While some cases may be misdiagnosed, many believe that ADHD is underdiagnosed as well, particularly among adults.

Clearly, a more rigorous system for diagnosing the disorder is needed. And parents, teachers, and physicians should be educated about what exactly ADHD is, and when a child or adult requires treatment.

But consider the days when depression was just starting to be treated with medications like Prozac — the public was horrified. There was a sense that depressed people were weak, popping pills to dampen normal human emotions like sadness and despair. And there was a concern that these medications could destroy or impair a person’s innate humanity. “It’s hard for people to believe,” says Faraone, “that normal human reactions could be at the root of a real disorder.”

FONTE: http://www.everydayhealth.com/adhd-awareness/the-rise-of-adhd.aspx#continue