PDF of full thesis available at Martin Whitely PhD Thesis Copy – ADHD and Regulatory Capture in Australia PDF
Like many first world nations, Australia has demonstrated an increasingly pharmaceuticalized response to Attention Deficit Hyperactivity Disorder (ADHD). Per capita rates of prescriptions of ADHD medications grew 277 percent between 1995 and 2010. However, there have been large and inconsistent intertemporal variations between state jurisdictions (shifting over time in relative terms). Most notably, in Western Australia (WA) in 2002 the child Pharmaceutical Benefits Scheme (PBS) per capita prescribing rate was 142 percent above the national average. However, after 2003, while in other states prescribing rates grew, they fell by 50 percent in WA, and by 2011 they were 11 percent below the national average.
There has been significant academic, public and media interest not only about the growing and inconsistent prescribing rates, but also about concerns that conflicts of interests and ‘regulatory capture’ may have affected significant policy development and regulatory processes in relation to ADHD. Regulatory capture occurs if an entity that is supposed to advance the public interest instead acts to benefit commercial or industry interests in ways that are contrary to the public interest.
The thesis draws heavily on the work of British sociologist John Abraham, who contends that regulatory capture is the most significant explanation of the process of pharmaceuticalization for many health conditions, including ADHD. Here key ADHD policy development processes are analysed to evaluate the extent of regulatory capture in Australian national and state jurisdictions. These include the development of national treatment guidelines and state-specific reviews of WA and New South Wales (NSW) prescribing practices.
For the purposes of this thesis, the term ‘regulatory capture’ is taken to have a broad scope, encompassing capture of any or all of the actors, both government and non-government, which have the declared intention of protecting and enhancing the public good. Examples of non-government actors include professional organisations, researchers, and patient advocacy groups.
The history of ADHD policy and regulation nationally from 1992 to 2012, in WA from 1993 to 2011 and in NSW from 2007 to 2011 is that regulatory capture occurred in the majority of policy development and regulatory processes. These ‘captured’ processes have been associated with subsequent ADHD child pharmaceuticalization. Conversely the only ADHD-critic dominated process identified occurred in WA in 2002 and was associated with subsequent ADHD child de-pharmaceuticalization. The findings of this thesis are consistent with Abraham’s assertion that regulatory capture is a significant driver of pharmaceuticalization.
The central hypothesis of this research is: The occurrence or absence of regulatory capture of the development and implementation of ADHD policy has contributed significantly to variations in Australian national and state ADHD medication child prescribing rates between 1992 and 2012.
Summary of ADHD prescribing statistics 1992-2011 (page 97)
Australian ADHD prescribing rates grew very rapidly between 1992 and 2011, with WA per capita rates growing much faster than the other states. By 2000, WA child prescribing rates were at least double the national average and adult prescribing rates were over four times the national rate. However, beginning in 2003, WA prescribing rates for children began to fall and by 2010 were approximately half of what they were in 2002.
Child prescribing rates, however, rose in all other states so that by 2011 WA rates were (approximately 11 percent) below the national average. In contrast NSW child prescribing rates, which were significantly below WA rates in 2000, have grown rapidly and are now significantly higher than WA rates. Other states have also demonstrated a pattern of increasing prescribing rates although South Australian and Victorian child prescribing rates both remain lower than WA rates.
WA’s adult ADHD prescribing experience has been significantly different from that for WA child prescribing. While there was a modest fall in the mid-2000s the rates have remained consistently much higher than all other Australian states.
Conclusion (page 241)
The purpose of this thesis was to examine the relationship between regulatory capture of ADHD policy and regulatory processes and child ADHD prescribing rates in Australia nationally and within state jurisdictions. The history of ADHD policy and regulation nationally from 1992 to 2012, in Western Australia from 1993 to 2011 and in New South Wales from 2007 to 2011 indicates regulatory capture and corresponding pharmaceuticalization is highly probable, but not inevitable. With the exception of Western Australia post 2001 and the balanced national ADHD Clinical Practice Point process in 2011-2012, all the other State and Commonwealth Government processes examined have been captured by ADHD proponents in the policy development and/or implementation phase. Even WA’s balanced 1997 Technical Working Party process was captured in the implementation phase when the Stimulants Committee set up as a result of the Working Party recommendations was captured by ADHD proponents.
All of these captured processes have been associated with subsequent ADHD child pharmaceuticalization, i.e. rapidly increasing per capita child prescribing rates. Conversely the only ADHD critic dominated process was associated with subsequent ADHD child de-pharmaceuticalization, i.e. rapidly falling per capita child prescribing rates. In summary the evidence in relation to Government policy and regulation indicates that in relation to ADHD in Australia for the period 1993 to 2011, regulatory capture leading to pharmaceuticalization was normal but not inevitable.
Australian regulatory capture has been reinforced by ‘imported regulatory capture’. Specifically there has been a pattern of selective attention to international research and practices favourable to the perspective of ADHD proponents. Most notably despite significant and substantiated concerns about improper pharmaceutical company influence upon the American Psychiatric Association (APA), Australian agencies, both government and non- government, have endorsed and promoted the use of the ADHD DSM-IV diagnostic criteria. Alternative diagnostic criteria in the International Clarification of Diseases 10 (ICD-10) produced by the World Health Organisation (WHO), has been consistently ignored by Australian regulatory agencies and stakeholders, despite Australia being a member of the WHO. The use of DSM-IV criteria are associated with increased prescribing rates as compared to jurisdictions relying on ICD-10. It is therefore likely that regulatory capture of the American Psychiatric Association has contributed significantly to Australia’s increasingly pharmaceuticalized response to ADHD.
Caution needs to be displayed in generalising the findings of this thesis. It relates specifically to ADHD in Australia and it is impossible to quantify the relative importance of the many factors that may influence prescribing rates. However, the positive relationship between regulatory capture and pharmaceuticalization demonstrated in this thesis is consistent with Abraham’s contention that ‘regulatory capture’ is the most significant driver of pharmaceuticalization in general and ADHD pharmaceuticalization in particular. Further research is warranted on the relationship between ‘regulatory capture’ and pharmaceuticalization for ADHD and other controversial medical/psychiatric conditions in Australia and other jurisdictions.