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Tag: bigger problem

  • Florida’s Experiment With Measles

    Florida’s Experiment With Measles

    The state of Florida is trying out a new approach to measles control: No one will be forced to not get sick.

    Joseph Ladapo, the state’s top health official, announced this week that the six cases of the disease reported among students at an elementary school in Weston, near Fort Lauderdale, do not merit emergency action to prevent unvaccinated students from attending class. Temporary exclusions of that kind while an outbreak is ongoing are part of the normal public-health response to measles clusters, as a means of both protecting susceptible children and preventing further viral spread. But Ladapo is going his own way. “Due to the high immunity rate in the community, as well as the burden on families and educational cost of healthy children missing school,” he said in a letter released on Tuesday, the state’s health department “is deferring to parents or guardians to make decisions about school attendance.”

    That decision came off as brazen, even for an administration that has made systematic efforts to lower vaccination rates among its constituents over the past two years. Ladapo’s letter acknowledges the benefits of vaccination, as well as the fact that vulnerable children are “normally recommended” to stay home. Still, it doesn’t bother giving local parents the bare-minimum advice that all kids who are able should get their MMR (measles, mumps, and rubella) shots, Dorit Reiss, a professor and vaccine-policy expert at UC Law San Francisco, told me. “I wouldn’t have expected him, in the middle of a measles outbreak, to be willing to sacrifice children in this way.”

    The Florida Department of Health has not responded to a request for comment on Ladapo’s future plans, should this situation worsen. For the moment, though, he has chosen to lower the guardrails from their standard height. It’s an escalation of his, and Florida’s, broader push against established norms in public health, especially as they relate to vaccination. So what happens now?

    At least in any immediate sense, Ladapo’s decision may not do much harm. In fact, there’s good reason to believe that its effects will end up being minimal. Parents who have children at the school, Manatee Bay Elementary, have until today to decide whether to pull out those kids for the next three weeks. Many seem to have already done so: About 200 students, and six teachers, have been absent, according to local news reports. In the meantime, Broward County Public Schools’ superintendent said yesterday that just 33 students out of the school’s nearly 1,100 were still unvaccinated. Given those two facts—some degree of self-imposed isolation, and 97 percent of the community now having some level of immune protection—the virus will have a hard time spreading no matter what the rules for attendance might be.

    Disease modeling, too, suggests that the risk of a larger outbreak is low. For a study released in 2019, a team of researchers based at Newcastle University and the University of Pittsburgh simulated thousands of measles outbreaks at schools in Texas, the most populous state to allow nonmedical exemptions from routine vaccine requirements. The researchers looked at the extent to which a policy of sequestering unvaccinated kids would help to reduce the outbreaks’ size. In the median outcome, even without any school-wide interventions, they found that an initial case of measles spreads only to a small handful of people. Adding in the rule that unvaccinated kids must stay at home has no effect on transmission. When the school’s vaccination rates are assumed to be unusually low, the rule reduces the outbreak’s size by one case.

    Not all the modeling outcomes are so rosy. For the very worst-case scenarios, in which a case of measles emerges in a school where unvaccinated kids happen to be clustered, the study found that forced suspensions have dramatic benefits. A major outbreak in the Dallas–Fort Worth area, for example, might end up infecting 477 people in the absence of any interventions, according to the model. When unvaccinated kids are kept from going to school, that number drops by 95 percent.

    Hypothetical models can’t tell us what will happen in a real-life school with real-life kids, like the one in Weston, Florida. But given Manatee Bay Elementary’s reported vaccination rate, it’s fair to assume that Ladapo’s policy won’t be catastrophic. Indeed, it may well end up sparing a few dozen families from the fairly serious inconvenience of being out of school without having much effect at all on the outbreak’s final size.

    But is the sparing of that inconvenience worth the risks that still remain? (And how should one value the time of a parent who could have vaccinated their child but chose not to?) As Reiss points out, if this policy leads to even one more case in the current outbreak, it will have put one more kid at risk of hospitalization, long-term complications, or even death. Worst-case outbreak scenarios do occur from time to time, as we all know well by now; and the Weston outbreak getting much worse is certainly within the realm of possibility. Any public-health authority would have to weigh these odds in the face of a six-case cluster; and surely almost every statewide health authority would choose to err on the side of caution. In Florida, though, the scale appears to tip the other way. Ladapo has rolled the dice on doing less.

    That’s been his way since the very day he was appointed by Governor Ron DeSantis, in September 2021. Just hours after he was introduced, the state ended mandatory quarantines for low-risk students who had been exposed to COVID. The following March, just a few weeks after being confirmed into the job, Ladapo announced that Florida would be “the first state to officially recommend against the COVID-19 vaccines for healthy children.” He continued to scale up from there: That fall, he recommended against the use of mRNA vaccines by any men under the age of 40. A year later, in October 2023, his office warned everyone under the age of 65 about the risks of getting an mRNA-based COVID booster. And then, finally, just last month, Ladapo came out with a warning that mRNA-based COVID vaccines “are not appropriate for use in human beings.”

    Read: The curious case of Florida’s pandemic response

    The man’s commitment to undermining vaccination is truly unparalleled among leading public-health officials. “As a surgeon general he stands alone,” Reiss told me. Yet Ladapo’s policy activism, however grotesque it might seem, has been bizarrely ineffective in practice. Take his March 2022 move to lead the way on not vaccinating young people against COVID. Media coverage of that announcement dwelled on reasonable concerns that this policy would dampen immunization rates; vaccine experts said it was a dangerous and irresponsible move that would “cause more people to die.” In practice, though, it seems to have done almost nothing. At the time of Ladapo’s announcement, 24.2 percent of Florida’s kids and 66.3 percent of its teenagers had received at least one dose of a COVID vaccine. (The corresponding national numbers at the time were somewhat higher.) By the end of the year, and in spite of Ladapo’s contrarian guidance, Florida’s vaccination numbers for these age groups were up by about four and three points respectively—which is almost exactly the same amount, percentage-wise, as the increases in those numbers seen across the country.

    Or compare Florida’s experience to that of Nevada, a state which had very similar child and teen vaccination rates in March 2022: 23.1 percent and 64.0 percent. Through the end of 2022, while Ladapo was discouraging his constituents from getting shots, that state’s Democratic governor was engaged in a large-scale effort to do just the opposite. And yet the results were essentially the same: Nevada’s rates increased by pretty much the same amount as Florida’s.

    For all of Ladapo’s efforts to dampen his state’s enthusiasm for life-saving interventions, Florida’s age-adjusted rates of death from COVID do not appear to have increased relative to the rest of the country, at least according to reported numbers. In this way, one of the nation’s loudest and most powerful voices of vaccine skepticism seems to be shouting into the wind. His proclamations and decisions to this point have been exquisitely effective at producing outrage, but embarrassingly feeble when it comes to changing outcomes. Even taken on its own terms, as a means of changing public-health behavior, Ladapo’s anti-vaccine activism has been a demonstrable failure.

    Read: The good news about vaccine hesitancy

    Perhaps this week’s decision to relax the rules on fighting measles will mark just one more step along that path: Once again, Florida’s surgeon general will have taken an appalling stance that ends up having no effect. But then again, now could be different. By the time Ladapo got around to undermining COVID shots, more than two-thirds of the state’s population, and 91 percent of its seniors, were already fully vaccinated. The damage he could have done was limited, by definition. But the measles outbreak in Weston is unfolding in real time. More such outbreaks are nearly guaranteed to occur in the U.S. in the months ahead. Reiss worries that Ladapo’s new idea, of choosing not to separate out unvaccinated kids during a school outbreak, could end up spreading into other jurisdictions. “If this becomes a precedent, that becomes a bigger problem,” she told me.

    For the first time since taking office, Ladapo may finally have a real opportunity to make a difference through his vaccination policy. That’s a problem.

    Daniel Engber

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  • Adult ADHD Is the Wild West of Psychiatry

    Adult ADHD Is the Wild West of Psychiatry

    In October, when the FDA first announced a shortage of Adderall in America, the agency expected it to resolve quickly. But five months in, the effects of the shortage are still making life tough for people with attention-deficit hyperactivity disorder who rely on the drug. Stories abound of frustrated people going to dozens of pharmacies in search of medication each month, only to come up short every time. Without treatment, students have had a hard time in school, and adults have struggled to keep up at work and maintain relationships. The Adderall shortage has ended, but the widely used generic versions of the drug, known as amphetamine mixed salts, are still scarce.

    A “perfect storm” of factors—manufacturing delays, labor shortages, tight regulations—is to blame for the shortage, David Goodman, an ADHD expert and a psychiatry professor at the Johns Hopkins University School of Medicine, told me. And they have all been compounded by the fact that the pandemic produced a surge in Americans who want Adderall. The most dramatic changes occurred among adults, according to a recent CDC report on stimulant prescriptions, with increases in some age groups of more than 10 percent in just a single year, from 2020 to 2021. It’s the nature of the spike in demand for Adderall—among adults—that has some ADHD experts worried about “whether the demand is legitimate,” Goodman said. It’s possible that at least some of these new Adderall patients, he said, are getting prescriptions they do not need.

    The problem is that America has no standard clinical guidelines for how doctors should diagnose and treat adults with ADHD—a gap the CDC has called a “public health concern.” When people come in wanting help for ADHD, providers have “a lot of choices about what to use and when to use it, and those parameters have implications for good care or bad care,” Craig Surman, a psychiatry professor and an ADHD expert at Harvard and the scientific coordinator of adult-ADHD research at Massachusetts General Hospital, told me. The stimulant shortage will end, but even then, adults with ADHD may not get the care they need.

    For more than 200 years, symptoms related to ADHD—such as difficulty focusing, inability to sit still, and fidgeting—have largely been associated with children and teenagers. Doctors widely assumed that kids would grow out of it eventually. Although symptoms become “evident at a very early period of life,” one Scottish physician wrote in 1798, “what is very fortunate [is that] it is generally diminished with age.” For some people, ADHD symptoms really do get better as they enter adulthood, but for most, symptoms continue. The focus on children persists today in part because of parental pressure. Pediatricians have had to build a child-focused ADHD model, Surman said, because parents come in and say, “What are we going to do with our kid?” As a result, treating children ages 4 to 18 for ADHD is relatively straightforward: Clear-cut clinical guidelines from the American Academy of Pediatrics specify the need for rigorous psychiatric testing that rules out other causes and includes reports about the patient from parents and teachers. Treatment usually involves behavior management and, if necessary, medication.

    But there is no equivalent playbook for adults with ADHD in the U.S.—unlike in other developed nations, including the U.K. and Canada. In fact, the disorder was only recently acknowledged within the field of adult psychiatry. One reason it went overlooked for so long is because ADHD can sometimes look different in kids compared with adults: Physical hyperactivity tends to decrease with age as opposed to, say, emotional or organizational problems. “The recognition that ADHD is a life-span disorder that persists into adulthood in most people has really only happened in the last 20 years,” Margaret Sibley, a psychiatry professor at the University of Washington School of Medicine, told me. And the field of adult psychiatry has been slow to catch up. Adult ADHD was directly addressed for the first time in DSM-5—the American Psychiatric Association’s diagnostic bible—in 2013, but the criteria described there still haven’t been translated into practical instructions for clinicians.

    Addressing adult ADHD isn’t as simple as adapting children’s standards for grown-ups. A key distinction is that the disorder impairs different aspects of an adult’s life: Whereas a pediatrician would investigate ADHD’s impact at school or at home, a provider evaluating an adult might delve into its effects at work or in romantic relationships. Sources of information differ too: Parents and teachers can shed light on a child’s situation, but “you wouldn’t call the parent of a 40-year-old to get their take on whether the person has ADHD,” Sibley said. Providers usually rely instead on self-reporting—which isn’t always accurate. Complicating matters, the symptoms of ADHD tend to be masked by other cognitive issues that arise in adulthood, such as those caused by depression, drug use, thyroid problems, or hormonal shifts, Sibley said: “It’s a tough disorder to diagnose, because there’s no objective test.” The best option is to perform a lengthy psychiatric evaluation, which usually involves reviewing symptoms, performing a medical exam, taking the patient’s history, and assessing the patient using rating scales or checklists, according to the APA.

    Without clinical guidelines or an organizational body to enforce them, there is no pressure to uphold that standard. Virtual forms of ADHD care that proliferated during the pandemic, for example, were rarely conducive to lengthy evaluations. A major telehealth platform that dispensed ADHD prescriptions, Cerebral, has been investigated for sacrificing medical rigor for speedy treatment and customer satisfaction, potentially letting people without ADHD get Adderall for recreational use. In one survey, 97 percent of Cerebral users said they’d received a prescription of some kind. Initial consultations with providers lasted just half an hour, reported The Wall Street Journal; former employees feared that the company’s rampant stimulant-prescribing was fueling an addiction crisis. “It’s impossible to do a comprehensive psychiatric evaluation in 30 minutes,” Goodman said. (Cerebral previously denied wrongdoing and no longer prescribes Adderall or other stimulants.)

    The bigger problem is that too few providers are equipped to do those evaluations in the first place. Because adult ADHD was only recently recognized, most psychiatrists working today received no formal training in treating the disorder. “There’s a shortage of expertise,” Surman said. “It’s a confusing space where, at this point, consumers often are educating providers.” The dearth of trained professionals means that many adults seeking help for ADHD are seen by providers, including primary-care doctors, social workers, and nurse practitioners, who lack the experience to offer it. “It’s a systemic issue,” Sibley said, “not that they’re being negligent.”

    The lack of trained providers opens up the potential for inadequate or even dangerous care. Adderall is just one of many stimulants used to treat ADHD, and choosing the right one for a patient can be challenging—and not all people with ADHD need or want to take them. But even the most well-intentioned health-care professionals may be unprepared to evaluate patients properly. The federal government considers Adderall a highly addictive Schedule II drug, like oxycodone and fentanyl, and the risks of prescribing it unnecessarily are high: Apart from dependency, it can also cause issues such as heart problems, mood changes, anxiety, and depression. Some people with ADHD might be better off with behavioral therapy or drugs that aren’t stimulants. Unfortunately, it can be all too easy for inexperienced providers to start a patient on these drugs and continue treatment. “If I give stimulants to the average person, they’ll say their mood, their thinking, and their energy are better,” Goodman said. “It’s very important not to make a diagnosis based on the response to stimulant medication.” But the uptick in adults receiving prescriptions for those drugs since at least 2016 is a sign that this might be happening.

    The fact that adult ADHD is surging may soon lead to change. Last year, the American Professional Society of ADHD and Related Disorders began drafting the long-needed guidelines. The organization’s goal is to standardize care and treatment for adult ADHD across the country, said Goodman, who is APSARD’s treasurer. Establishing standards could have “broad, sweeping implications” beyond patient care, he added: Their existence could compel more medical schools to teach about adult ADHD, persuade insurance companies to cover treatment, and pressure lawmakers to include it in workplace policies.

    A way out of this mess, however long overdue, is only going to become even more necessary. Nearly 5 percent of adults are thought to have the disorder, but less than 20 percent of them have been diagnosed or have received treatment (compared with about 77 percent of children). “You have a much larger market of recognized and untreated adults, and that will continue to increase,” Goodman said. Women—who, like girls, are historically underdiagnosed—will likely make up a substantial share. Adults with ADHD may have suffered in silence in the past, but a growing awareness of the disorder, made possible by ongoing destigmatization, will continue to boost the ranks of people who want help. On social media, ADHD influencers abound, as do dedicated podcasts on Spotify.

    Until guidelines are published—and embedded into medical practice—the adult-ADHD landscape will remain chaotic. Some people will continue to get Adderall prescriptions they don’t need, and others may be unable to get an Adderall prescription they do need. Rules alone couldn’t have prevented the shortage, and they won’t stop it now. But in more ways than one, their absence means that many people who need help for ADHD are unable to receive it.

    Yasmin Tayag

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