It is stated that the primary psychopharmacological agents used in ADD are central nervous system stimulants. Representatives of this group are methylphenidate, dextroamphetamine and pemoline. There are many amphetamines available, including methamphetamine and dextroamphetamine. However, dextroamphetamines are more preferred. Methylphenidate is used more than any other stimulant. At least 70% of children respond positively to one of the main stimuli on their first try. If the clinician is using either dextroamphetamine, methylphenidate or pemoline, the response rate to at least one of these drugs varies between 85% and 90%.
The main purpose of giving medication is to improve classroom behavior, academic achievement and productivity. In ADD, which is accompanied by Defiant Disorder, Severe Conduct Disorder, and aggression, there is information that the drug also helps with these complaints. Relationships between the child and peers, family, teachers and other important people are also improving. In addition, it is stated that participation in leisure time activities has increased. It is claimed that the main message in the use of stimulants is to emphasize that it is not just a “school time drug”. It is recommended to be used at all times when awake and on weekends. In our department, the general practice is to make children use drugs during school times. There is no preference for the drugs used in ADD. Some children may respond better to one drug and worse to another, and this cannot be predicted.
The appearance of side effects varies from child to child and from drug to drug. Most of the side effects disappear over time or with different approaches. Suppression of growth is attributed to the dose of the drug if it occurs. Monitoring studies can reach the expected height and weight of the child, albeit with a delay. However, it is seen that some children cannot adapt to this developmental delay. It is comforting that the drug does not lose its effectiveness after puberty and does not lead to drug abuse. However, stimulant use is controversial in individuals with a personal or family history of substance abuse.
The effect of stimulant drugs on tics gives conflicting results. Some children diagnosed with ADD present to clinics with vocal or behavioral tics. Sometimes these children’s tics increase with the use of stimulants. According to the latest findings, these complaints return to their former state after a while, even if the drugs are continued. If there is no improvement, the addition of drugs such as haloperidol, pimozide or clonidine helps the symptoms disappear.
“Rebound” is the deterioration in behavior after the use of short-term stimulants. This deterioration period can be half an hour or more. This is observed in very few children. The rebound effect can be resolved with the use of long-acting drugs
In some cases, the dose required for the effect of the drug on behavior may not match the dose required for improvement in mental processes. In such cases, the lower dose should be preferred.
In a 1994 review of more than one hundred publications, 4500 primary school children were evaluated. Studies with preschool children are much fewer (about 130 subjects). Studies with adolescents (about 113 subjects) and adults (about 180 subjects) are also very few. Outcomes for preschool and adulthood vary widely.
Information on non-stimulant drugs used in the treatment of ADD in recent years has been searched. The drugs evaluated were antidepressants, ct2 adrenergic receptor blockers (clonidine and guanfacine), neuroleptics, fenfluramine, lithium, and anticonvulsants. It is claimed that the best studied agent in this regard is heterocyclic antidepressants. Some studies show that 70% of children with ADD respond to desipramine at doses up to 5 mg/kg. It has been observed that all heterocycles have positive effects on hyperactivity, inattention, anxiety and depressive affect. The effects on learning are not very clear. Its main side effect is on the cardiovascular system. It is stated to cause arrhythmia in particular. The sudden death of several young children has highlighted the need to reconsider the use of heterocycles.
Bupropion is a serotonin reuptake blocker and a non-tricyclic antidepressant. It is stated that the side effect profile is positive. It is recommended to administer 5-6 mg/kg daily in three divided doses.
Information on selective serotonin reuptake inhibitors such as fluoxetine, sertraline, proxetine and fluvoxamine is limited, but positive results have been reported in a small number of children. In a recent study, it was found that 78% of 32 subjects aged 9-17 diagnosed with ADD had mood disorders such as dysthymia and 80% had major depressive disorder. Addition of fluocetine to ongoing methylphenidate therapy resulted in significant improvement in 30 of the patients.
Monoamine oxidase inhibitors have been studied in very few studies and in very few children. Results are stated to be equivalent to dextroamphetamines. However, possible drug and dietary responses limit its use.
Information on the use of clonidine and guanfacine alone in Attention Deficit Disorder is limited. Its use together with stimulant drugs has a positive effect on the aggressive/hyperactive behavior dimension or tics in addition to ADD. However, it was reported that the combination of clonidine/methylphenidate caused sudden death in three children. The role of drugs in this regard is unknown. The effect of fenfluramine, a synthetic stimulant, has not been demonstrated on DEB. It has become clear in clinical follow-ups that a possible positive effect can be mentioned in mentally handicapped and pervasive developmental disorders.
Mood stabilizers such as lithium, carbamazepine and valproic acid have not been shown to have a positive effect on the main symptoms of DEB.
Some studies conducted with neuroleptics in previous years have given findings that they are effective in some symptoms. It is not used today due to possible negative side effects. However, the addition of haloperidol or pimozide to stimulants is beneficial in tics or Tourette’s disorder.
(((Although there are many studies and discussions about the stimulant drug Ritalin (methylphenidate), which has been used in the treatment of hyperactivity and attention deficit (HADE) for 40 years), has various negative effects, especially addiction (ref:2,3, 4,5,6,7,8,10,11,14,15,16), this “red prescription” drug, which is in the category of the most dangerous drugs, is still widely used.
America, the world Although it constitutes 5% of the population, it consumes 90% of Ritalin produced in the world and the use of this drug has increased by 700% since the early 1990s. Research on addiction
The only truly long-term longitudinal study, to date, that has been done in real-life conditions rather than in laboratory or clinical conditions is that children with HADE who used Ritalin for more than one year compared to children with HADE who never used Ritalin after 20 years. , approximately They have shown that they are TWICE ADDICTIVE TO COCAINE AND CIGARETTES (ref:10,11) This 1998 paper by University of California, Berkeley psychologists Lambert and Hartsough, also cited in one sentence, titled “Attention: Ritalin Looks Like Cocaine” (ref:16). The research stands out with its very reliable methodology and the fact that it was conducted “independently”, so the research findings are undeniably strong. Nora Volkow, a psychiatrist and neuroimaging specialist at New York’s Brookhaven National Laboratory, found that drug addicts love Ritalin when injected as a liquid. Volkow and colleagues, a leading team in neuroimaging on the effects of chemicals, have been investigating the effects of addictive drugs and substances on the brain for years using positron emission tomography (PET) and other advanced techniques. Among the long list of findings is that compulsive behaviors, such as substance use and binge eating, are linked to the dopamine system in the brain.
A Paradox As an extension of this research, Volkow, chief of the life sciences laboratory at Brookhaven, set out to uncover the unknowns of a legal stimulant drug, Ritalin. Although it has been used for the treatment of HADE for nearly 40 years, psychiatrists and pharmacologists still do not know how or why the drug works. Chemically similar to cocaine and other stimulants, methylphenidate presents a strange paradox: although it is a substance that normally increases activity, in people with HADE it strangely reduces activity and helps focus. However, studies show that 50 percent of people who don’t have HADE say that when they take this substance, they experience an unpleasant condition similar to drinking too much coffee.
During a press release, Volkow was speaking that I’ve almost become obsessed with uncovering how methylphenidate works through neuroimaging. As a psychiatrist, I am ashamed to know nothing about the drug, because it is a drug that we give intensively to children, not adults. On top of that, Volkow and his team found the dopamine system, which stimulates reward and motivation circuits during pleasurable experiences such as learning, eating, and sex. They began to examine it with PET scans. For example, to choose one of the pleasurable experiences, tasting chocolate ice cream triggers cells in the basal ganglia to release dopamine molecules. These molecules activate in spaces called synapses to form an interneuronal reward circuit. Receptors on neurons absorb dopamine, activating signals that could be translated as the experience worth paying attention to. If the signals are too many, the experience is unpleasant and over-stimulating, if too little, it leads to yawning, boredom, and an inability to focus.
Volkow is trying to find out how methylphenidate (Ritalinin) affects these signals. But instead of focusing on dopamine receptors, Volkow tracks another part of the system. After the gratification signals are sent, the dopamine molecules return to the neurons that produced them. At that point, the transporters, also called auto-receptors, come into play and work like a vacuum cleaner to clean the synapses for a new circulation. Previous research has shown that cocaine blocks 50% of these transporters, thus increasing the dopamine in the synapse excessively and peaking the sense of pleasure. showed that he had hit.
The situation in Turkey;
Since 2003, when the Health Transformation Project started to be implemented, total health expenditures have unfortunately been in a significant upward trend. Today, instead of preventive and preventive health care, the therapeutic health care approach focused on the consumption of drugs and medical technology, on which we are largely dependent on foreign sources, is dominant today. As an inevitable result of this, our pharmaceutical market has become one of the fastest growing markets in the world.
Turkey, on the other hand, is one of the top 5 countries in the world where the pharmaceutical market has grown the most, with a growth rate of 17.2%. For example, while importing drugs worth 2.491 billion dollars in 2003, this amount reached 4.360 billion dollars in 2008. When the export amounts in the same years are evaluated, while Turkey’s pharmaceutical exports in 2003 were 246 million dollars, it increased to 421 million dollars in 2008. Although it creates the impression that there is no significant difference when evaluated proportionally, when evaluated in terms of price increase, the difference between imports and exports grows exponentially. When the import and export rates in developed countries are evaluated, Turkey’s foreign dependence on pharmaceuticals emerges much more strikingly. For example, while the ratio of pharmaceutical exports to imports in Turkey was 10% in 2005; This rate is 122% in Germany, 207% in Switzerland, 133% in France, 141% in England, 95% in Italy, 263% in Sweden and 268% in Denmark.
Three of the top 10 most profitable drugs worldwide are antipsychotics. In 2009, the total pharmaceutical market in the world is expected to reach 820 billion dollars.
It is stated that the liberalization of SSK patients’ purchase of drugs from pharmacies and the cessation of the production of SSK pharmaceutical factory have an important role in the rapid growth of the Turkish pharmaceutical market. After this implementation, in 2005, the Turkish pharmaceutical market became the country with the 10th largest pharmaceutical market in the world, and it is expected to maintain this market share in 2009 as well.
Turkey surpasses all developed countries. The ratio of drug consumption to national income in 2006 in Turkey is 1.75%, which is even higher than the USA (1.5%), which is by far the world leader in drug consumption. In England, this rate is 0.65%.
When considered in terms of Turkey, nervous system drugs occupy an important place in the pharmaceutical market. Nervous system drugs are in the 4th place in the Turkish pharmaceutical market after antibiotics, cardiovascular system and rheumatic drugs. In addition, when the market share of pharmaceutical groups in Turkey between the years 2003-2008 is evaluated; While the market share of antibiotics, cardiovascular system and rheumatic drugs group decreased, a moderate increase is observed in the market share of nervous system drugs.
For example, according to IMS-Turkey data, 14 million 138 thousand boxes of antidepressants were consumed in 2003, while this figure increased to 22 million 651 thousand according to 2006 data and 26 million 246 thousand in 2007. A similar upward trend is also seen in antipsychotic drugs; While a total of 2 million 616 thousand 136 boxes of antipsychotics were consumed in 2007, this number increased to 4 million 11 thousand 901 boxes in 2008. In addition to the promotion efforts of the pharmaceutical industry, the insufficient number of psychiatrists in Turkey and therefore the prescription of drugs that are not suitable for inappropriate diagnoses by physicians other than psychiatrists have a very important role in this significant increase in psychiatric drug consumption.
