No doubt that, even as we speak, worried pundits are writing of how this is a worrying Orwellian scenario and yadda yadda. But what's really going on?
The research is from Sweden and published in the New England Journal of Medicine: Medication for Attention Deficit–Hyperactivity Disorder and Criminality. The first thing to note is that the study is not about giving medication in order to prevent crime; it was purely looking at what happened to people given ADHD treatment for their ADHD.
It was a huge study with over 25,000 ADHD patients and the data comprise pretty much everyone in Sweden over the relevant period so in that respect it's a very good study - although speaking of Orwellian, these studies are only possible because of the Scandinavian tendency to make national registers of everything.
Now the big criticism here is that it's just a correlation, it doesn't prove that the meds were what prevented crime. It might be that ADHD meds have no effect on crime, but that people are less likely to commit crimes at periods when they have their lives sorted out (when they're 'on the rails'), one marker of which is that they're seeking treatment for their ADHD.
However, the authors found that periods of use of SSRI antidepressants were not associated with changes in conviction rates. This is quite good evidence against the 'on the rails' critique, assuming that being prescribed SSRIs is as much a marker of being on the rails as being prescribed Ritalin is.
So, in my view, this is pretty good work, as good as any observational non-randomized study. However, remember: this is just about treating ADHD. Not drugging criminals to stop crime.
Lichtenstein P, Halldner L, Zetterqvist J, Sjölander A, Serlachius E, Fazel S, Långström N, and Larsson H (2012). Medication for attention deficit-hyperactivity disorder and criminality. The New England journal of medicine, 367 (21), 2006-14 PMID: 23171097
14 comments:
It's difficult to draw anything more than very tenuous causal conclusions here. For starters, treatment itself is associated with much more than just a drug effect. On this count, the authors report:
"To avoid possible bias from reverse causation (i.e., that patients stop treatment because of their criminal behavior, rather than the other way around), we investigated whether the order of the change in medication status was important. The associations were significant regardless of the order." [emphasis mine]
Even assuming the association were unidirectional, this would still leave open the question of whether drug effects per se are causal. That is, this result is still inherently confounded by the question of why some people with an ADHD diagnosis received treatment whereas others did not (treatment factor). Given that the underlying reason for the receipt of treatment might directly relate to the criminal behavior itself, this correlation is almost impossible to tease out from this dataset.
The fact that no similar effect is seen for SSRI treatment doesn't solve the problem because the relation between this treatment factor and criminality is unlikely to be consistent across different medications: SSRIs and ADHD meds are often prescribed for very different symptoms and so the reasoning behind treatment may not be the same.
And, of course, the obvious question: what happens to levels of Swedish criminality when you prescribe everyone a placebo pill which "helps to control your behaviour"?
Can't see the whole paper due to NEJM paywall (don't get me started on academic paywalls) but agree wih previous comment 100%. Would be interested to know if one potentially large confounding factor was considered: the likelihood that Ritalin patients likely to be accompanied by social support/mental health after-care which may in itself be a powerful protective factor for re-offending. SSRI results interesting, but in the UK at least, GPs are responsible for most SSRI scripts so little potential correlation with protective factors of professional input.
Still, big study, huge implications, and amazed Daily Mail haven't picked up as yet.
There is only one way to establish causation and that experiment will never be done. IMO studies like these are better left undone. They only erroneously bolster the position of those (eg. Pharm companys) that would like to see causation and these drugs are not harmless.
Perhaps they committed more crimes in periodes they were off Ritalin because of withdrawal symptoms. People can feel very off balance when Ritalin is stopped, not because of their adhd but because of imbalance related to stopping Ritalin.
You should compare crime rates between people never medicated for adhd en people (often) medicated for it.
Anonymous: It's possible, but they found that the reduction in crime after starting meds was larger than the increase after stopping. And they also found benefits in people who only started them once.
Good news for rehab facilities. Getting off ritalin is harder then getting off crack coke.
Invest in them, those clinics are going to spread like wildfire in 10 years.
I think that people who start on SSRI's are far from "on the rails". Why start with SSRI's when everything is starting to look good...? Not really a good comparison.
Seems like there would be an obvious link between reduced impulsivity from the medication and reduced criminal behavior, no?
Perhaps because they got their stimulants without being defined as 'criminals' whilst us mortals can get put in prison for our coke and speed habits?
The outcome here is criminal convictions, not criminality per se (which would be much harder to measure, of course). It seems plausible that poorly controlled ADHD would significantly increase one's likelihood of being caught and/or convicted. So, perhaps: "Ritalin, the Ultimate Criminal Performance Enhancer" instead?
If so, the only solution is to give the police Ritalin too.
I don't take Ritalin, my shrink has me on generic Adderall. If one -needs- these medications for the intended purpose, then what is the point of unsupervised, unrecommended withdrawal? Self-medicating can be harmful to you and others.... Don't you think there's a reason these drugs aren't sold OTC? Would you rather use meth or cocaine? I sure wouldn't, but I'm not an EU citizen. The nanny state here looks very harshly on narcotraficantes and their customers.
I don't take Ritalin, my shrink has me on generic Adderall. If one -needs- these medications for the intended purpose, then what is the point of unsupervised, unrecommended withdrawal?
I've done unsupervised withdrawal from dexamfetamine. By running out of my script, finding out I had to wait six weeks to see my shrink and I can't see another one because of the regulation of high risk drugs in Aus. I have a disease that makes treating the disease hard.
One anonymous poster wrote:
Anonymous said...
//There is only one way to establish causation and that experiment will never be done. IMO studies like these are better left undone. [...]
29 November 2012 21:10 //
I'm curious what this 'one way to establish causation' is?? Randoms assignment to groups, untreated 'controls', double blind procedures?
I think if you get right down to it, *no* experiment in medical treatment is going to satisfy 'anonymous', i.e. decisively prove 'causation.' For one thing, you can't properly set up a matched group for an ADHD group; the reasons ADHD arises are not well known.
Others posters have given good reasons to question the study, but applying a standard of perfection is not really helpful, here.
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