Wednesday, February 26, 2014

Is Mindfulness Doomed to Become a Fad?

Is mindfulness already a fad or doomed to become one? I started thinking about this recently after reading a blog post by Dr. David Allen, who wrote: "The latest fad in both psychotherapy and self help is 'mindfulness.'" While I agree with his article's point that it's better to help people change their environment if the environment is causing them distress, I thought calling mindfulness a "fad" seemed overly dismissive.

Mindfulness is certainly becoming more popular. Multiple therapies have been developed in recent decades that incorporate it, including mindfulness-based cognitive therapy (MBCT), acceptance and commitment therapy (ACT), and dialectical behavior therapy (DBT). Jon Kabat-Zinn's mindfulness-based stress reduction (MBSR) program predates those therapies and has resulted in numerous books, CDs, and workshops. Google has a mindfulness class called Search Inside Yourself, and there's even a mindfulness conference for tech types, Wisdom 2.0.

Has it all gone too far? To find some objective evidence, I used Google Trends to compare mindfulness with some other therapies that people may search for online.

Mindfulness certainly appears to be ascending rapidly, while the other therapeutic modalities show a slow but steady decline in search interest. But does this constitute a fad? Google defines "fad" as "an intense and widely shared enthusiasm for something, esp. one that is short-lived and without basis in the object's qualities; a craze." Here's the Wikipedia entry about fads:
A fad is any form of behavior that develops among a large population and is collectively followed enthusiastically for a period of time, generally as a result of the behavior being perceived as popular by one's peers or being deemed "cool" by social media. A fad is said to "catch on" when the number of people adopting it begins to increase rapidly. The behavior will normally fade quickly once the perception of novelty is gone.
Though the term trend may be used interchangeably with fad, a fad is generally considered a quick and short behavior whereas a trend is considered to be a behavior that evolves into a relatively permanent change.
I turned to Google Trends again, this time comparing mindfulness to a few things that definitely struck me as fads: low carb diets, acai berries, and twerking (which granted may be more of an Internet meme).

As you can see, mindfulness thus far has not behaved like these other fads. The low-carb craze was at a peak when Google first came to life in the early 2000's, dropping rapidly but having mini-peaks each new year as people explore dieting options. Searches for "acai" and "twerking" took off, but then fell fairly rapidly, though it seems the tails can stretch on for years. This graph seems to concur with my professional experience: when I ask my adult patients about their knowledge of mindfulness, out of 10 people, only 3 or 4 have ever heard of it, and out of those, only 1 might have a vague notion of what it means.

The enthusiasm for mindfulness is certainly more prevalent amongst therapists and academics than the general population, as shown by the rapid increase in Pubmed articles containing "mindfulness:"

I believe that this interest by itself does not constitute a fad, as long as the research bears fruit. Time will tell, and based on my own experiences in using mindfulness-based approaches with my patients, I'm optimistic that the evidence base in support of mindfulness will only continue to grow. More worrisome is the possibility that corporate America may be (mis)using mindfulness to make its workers more productive and less stressed, rather than creating less stressful work environments. Other people more knowledgable about mindfulness than I have written thoughtful articles about the commercialization of mindfulness and its implications. I especially recommend Beyond McMindfulness by Ron Purser and Beyond McMindfulness: A Thoughtful Reply by Elisha Goldstein.

And then there's this depiction of mindfulness in the popular culture:

You can certainly be forgiven for looking at the Time cover and thinking, "how can that not be a fad? Or at the very least a trend?" I would argue that mindfulness is neither of those things, since it's a concept that is so helpful for well-being, has been in use for thousands of years, and the idea of being present and focusing on the here-and-now is central to many therapeutic interactions. I would argue that mindfulness is analogous to physical exercise, which is also important for health. Nobody calls exercise a fad. But specific commercialized forms, endorsed by celebrities, overselling the benefits and underselling the necessary effort, can certainly constitute fads. Putting Photoshopped blondes meditating on the cover of Time to sell magazines? I certainly hope that's a fad.

Sunday, February 9, 2014

ADHD: The Big Picture

The January 2014 issue of JAACAP had an article detailing the rise in ADHD rates over the past decade: "Trends in the Parent-Report of Health Care Provider-Diagnosed and Medicated Attention-Deficit/Hyperactivity Disorder: United States, 2003–2011." The study is part of the CDC's National Survey of Children’s Health, and the authors reported the following results (the 2011 numbers had previously been widely reported elsewhere):
In 2011, 11% of children/adolescents aged 4 to 17 years had ever received an ADHD diagnosis (6.4 million children). Among those with a history of ADHD diagnosis, 83% were reported as currently having ADHD (8.8%); 69% of children with current ADHD were taking medication for ADHD (6.1%, 3.5 million children). A parent-reported history of ADHD increased by 42% from 2003 to 2011. Prevalence of a history of ADHD, current ADHD, medicated ADHD, and moderate/severe ADHD increased significantly from 2007 estimates. Prevalence of medicated ADHD increased by 28% from 2007 to 2011.
To me, the most interesting figure in the paper was a map of the U.S. showing how rates of parent-reported ADHD and medication treatment varied by state. Here's the map of what percentage of children in each state had a parent-reported diagnosis of ADHD:

Unfortunately, the authors do not even mention this large geographic variation in the paper's discussion section, and neither does the accompany editorial, titled "Beyond Rising Rates: Personalized Medicine and Public Health Approaches to the Diagnosis and Treatment of Attention-Deficit/Hyperactivity Disorder." Drs. Walkup, Stossel, and Rendleman from Weill Cornell Medical Center made the following argument:
In summary, the public health goal to improve recognition and treatment of ADHD is paying off in the United States. The rate of parent-reported ADHD diagnosis looks similar to community- based prevalence estimates. The rate of medication use approaches 70% of currently diagnosed cases, suggesting a substantial proportion of those with ADHD diagnoses are receiving treatment. It is important to not over-react simply to the notion of increasing rates of diagnosis and treatment without considering the whole picture. It is absolutely critical to benchmark current diagnosis and treatment rates against prevalence estimates to best serve the public health.
This editorial is one of the more ridiculous things I have ever read in an academic journal. First, as is widely known, ADHD misdiagnosis is rampant, which I have previously blogged about. Second, if we're to talk about a public health approach, to me that would go beyond identifying children with ADHD and medicating them; it would entail trying to figure out why rates of ADHD are so much higher in certain places than others, and then trying to address the root causes that contribute to those regionally higher rates.

Around the same time I read this JAACAP article, I read about the release of a landmark report on social mobility in the United States. The report, by the National Bureau of Economic Research, examined the incomes of over 40 million parents and their children from 1996 to 2012, looking at the factors that influenced how well the offspring did economically. Again, I was fascinated by a map showing how rates of upward mobility differed across the U.S.:

While the maps are obviously not identical, they are similar in that the Deep South and Rust Belt stand out on both, with higher rates of ADHD and lower levels of income mobility. I wish that the CDC study had more detailed local prevalence data than the state-level numbers, so the two maps could be more directly compared. The economists examined factors correlated with upward mobility and found:
High mobility areas have (1) less residential segregation, (2) less income inequality, (3) better primary schools, (4) greater social capital, and (5) greater family stability.
I would not be surprised if many of the above factors – especially family stability – also influence regional variation in ADHD rates. But regardless of the reasons behind the variation in ADHD diagnosis, it's clear to me that ADHD is not just a "brain condition," and I wish that more psychiatrists would be interested in investigating the bigger picture.