Thread by @PulpLibrarian

Ritalin was "the mild psychostimulant" that nobody bought. Yet today such stimulants are widely used to manage a range of behavioural issues, often in young children. How did we get here? And why do we prescribe so much?

Let's take a look...

Methylphenidate was first synthesized in 1944 by chemist Leandro Panizzon. He named the drug after his wife Rita, who used the new drug 'Ritalin' to manage low blood pressure. It also apparently improve her tennis game.

Ritalin is a psychostimulant that increases the activity of the central nervous system. The availability of norepinephrine and dopamine in the CNS is increased, speeding up brain activity - including in brain areas responsible for concentration and executive decision making.

Initially Ritalin was marketed to doctors as a ‘pep pill’ for the elderly and the withdrawn. But sales were not great: compared to existing amphetamines it wasn't as effective.

Perhaps that's just as well. The addictive nature of amphetamines like Benzedrine were already well documented: sold as a decongestant in 1933, by the 1940s it was a widely used stimulant for the military. There was plenty of evidence for its troubling side effects.

But there was also evidence for a possible beneficial effect: psychiatrists working with troubled children in Rhode Island had noticed that stimulant drugs could have a positive effect on their academic performance and behaviour.

Why would a psychostimulant help a child with behavioural issues? Possibly the brain areas that manage impulse control and concentration may operate more effectively when stimulated by amphetamines. The Rhode Island research spurred Ritalin's parent company to investigate...

In 1963 a randomized clinical trial showed that Ritalin improved behavioral symptoms in children labelled as 'troubled': from so-called “disobedient” behaviour to “lying.” Ritalin was soon approved for prescription to children; sales quickly increased.

So what was Ritalin actually treating? What is a 'troubled child'?

The term Hyperkinetic Impulse Disorder was coined in 1957, followed by Minimal Brain Disorder in 1963. By 1987 Attention Defecit Hyperactivity Disorder had become the term doctors increasingly used.

Despite being widely studied the exact causes of ADHD are unknown in the majority of cases. The behaviours - inattention, hyperactivity, acting without considering the consequences - are well documented. So is the huge rise in diagnoses.

In 1970 around 100,000 children the US were prescribed Ritalin. Today it's six million. And Ritalin is only one of many ADHD drug treatments now available.

How did the numbers get so large?

Some have accused drug companies of marketing the problem as much as the cure. ADHD doesn't have an underlying cause or genetic marker - diagnosis is based on observation and linking this to an underlying cause that can respond to drug treatment.

But it's also the case that we may have historically under-recognised the prevalence of behavioural problems in children and adults. Did we really underestimate the issue by so much? Parents are feeling battered by the range of opinions about ADHD.

It's certainly the case that there are more prescription drugs available for more behavioural and mental health issues than ever before, and they are increasingly used as a first line of treatment.

But it's also too easy to say 'drugs are not the answer' when you aren't suffering with the problem. That said, it should be down to an informed discussion with a doctor to agree the best course of treatment. Pressuring people with adverts or commentary rarely feels right.

It's important we separate the clinical evidence about drugs from the wider debate about how we diagnose and help people whose behaviour doesn't confirm to social norms. That conversation still needs to happen though: patients must have a voice, as well as a choice.

Valium, Prozac, Ritalin: they have all become shorthand for complex debates about mental health, wellbeing, and the society we live in. Debate is healthy, but the Hippocratic Oath must always be observed: first, do no harm.

More stories another time...