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ADHD in Japan: A Personal Perspective

225px Flag of Japan.svg  ADHD in Japan: A Personal PerspectiveThe “Land of the Rising Sun”…
The home of Samurai and Ninja…
The birthplace of Sony, Nintendo, and countless other technology companies which have changed our world…
The originators of Anime and Manga…
The manufacturers of Toyota, Honda and many other cars…

Japan is a country with a rich history, a strong economy, a fascinating culture, and it has a big influence on our modern world. For these reasons and others, I was very excited that I was invited to teach Japanese doctors about ADHD in early March 2012. While I was there, I presented to, and met many Japanese Child Psychiatrists and Pediatric Neurologists. I had many discussions with them about their work with ADHD.

In this blog post, I’ll share some of what I learned while I was there, and I’ll share some of my personal opinions about ADHD in Japan. Please note – this blog post really is my personal opinion. I did not see patients in Japan, I was only there for 6 days, and I did not conduct any research while I was there. Although I’ve gathered information and formed some opinions, I clearly cannot say that I have a strong grasp of Japanese culture, nor the mental health system in Japan, nor all there is to know about ADHD in Japan. That said, I hope that my thoughts can help you to understand more about ADHD in Japan. (And if you read this article, and find that my opinion has some factual inaccuracies, please let me know if the comments, and I’ll do my best to fix them.)

(and after sharing my opinions about ADHD in Japan, I’ll share about my experiences with traveling in Japan, so stay tuned…)

Firstly, you may wonder: Do kids and teens have ADHD in Japan? Do they get diagnosed, and are they prescribed medication?

The answer is: yes and yes.

Kids and teens are diagnosed with ADHD in Japan, and they are prescribed medication when they are diagnosed.

In general, to get a diagnosis of ADHD in Japan, one needs to see a Child Psychiatrist or Pediatric Neurologist. To get an assessment, a family would go directly to the specialist, as there aren’t family doctors or general practitioners in Japan. The specialists use the same assessment and diagnosis process that doctors in North America and Western Europe do.

In many ways, the challenges with getting diagnosed with ADHD are similar in Japan as they are in other parts of the world. By this I mean that there is stigma around mental health issues, and a significant reluctance for parents to give children medication. In addition to the challenges around acceptance of the diagnosis of ADHD and the use of medication which go on all over the developed world, in Japan, there have been significant issues with stimulant abuse and misuse. This has led to even more concerns around the proper use of ADHD medication in Japan. Here is a link to an article published in 1989 about stimulant abuse in Japan. There were renewed concerns about stimulant abuse in 2007, which are summarized below.

I learned about one very interesting cultural difference around ADHD diagnosis and treatment in Japan. In Japanese culture, it is important to respect other people’s personal space. When a child with ADHD has hyperactivity/impulsivity, which includes a symptom like: “interrupts and intrudes on others”, then their parents are often very concerned about this symptom, because it breaks the cultural norm. As such, parents of a child with this symptom may be more inclined to get their child diagnosed with ADHD, and they would be more inclined to give their child medication to help with ADHD. While this may be good to ensure that these children get the help that they need, it can also work against longer term treatment. In other words, when that symptom goes away (and the child is no longer interrupting and intruding on others), the parent is more likely to stop treating their child with medication. And even though that hyperactive/impulsive symptom is resolved, the child may have many other challenges with ADHD (such as inattention, restlessness, social problems, etc.).

While talking with Japanese specialists about their ADHD patients, it seemed to me that parents of kids and teens with ADHD go through issues of frustration and guilt, as they do in North America. Although I didn’t meet parents of kids and teens with ADHD in Japan to discuss this issue with them, I have a suspicion that the frustration and guilt that parents experience may be more in Japanese culture around ADHD than in Western countries.

What About Medication for ADHD in Japan?

When it comes to medication for ADHD in Japan, there are very few options. While Ritalin is available in Japan, it is illegal for it to be used for ADHD (it is currently only approved for narcolepsy). In October 2007, there was a crisis which happened in Japan over Ritalin, and a concern around its abuse. There were articles in a major Japanese newspaper – The Yomiuri (which at this point are not available on their website – and if they are, they aren’t in English). There was a significant tightening of rules around the use of stimulants for ADHD. Although I can’t access any source materials for this story, a user on ADD Forums posted a quote from the news story, when it was happening (you can find the post here). The quote said:

A panel of the Health, Labor and Welfare Ministry on Wednesday decided to remove the psychotropic drug Ritalin from its list of approved medicines to treat depression as it has become widely abused.

Following the decision by the pharmaceutical and food sanitation council, the ministry within this month will restrict the prescription of the highly addictive drug solely for the treatment of narcolepsy.

Ritalin is the brand name of methylphenidate hydrochloride, a central nervous system stimulant.

To prevent a further increase of the abuse of the drug, especially among young people, the ministry ordered Novartis Pharma K.K., the pharmaceutical company that produces and distributes the drug, to develop a system to manage its distribution.

The Minato Ward, Tokyo-based company plans to set up the system by early next year.

Under the new system, which is as strict as that applied for narcotics for medical use, doctors with expertise in diagnosing narcolepsy as well as medical institutions and pharmacies that prescribe the drug will be required to be preregistered.

Also at the panel meeting, Janssen Pharmaceutical K.K. proposed the same management system regarding the distribution of Concerta, a drug used to treat attention-deficit hyperactivity disorder.

(Oct. 19, 2007)

Prior to the release of Concerta in Japan, there were no medications officially approved for the treatment of ADHD. Doctors were treating ADHD with Ritalin, but Ritalin was only approved for the treatment of Depression and Narcolepsy. Because of the issue described above, Ritalin was only approved for Narcolepsy, and doctors are no longer allowed to use it to treat ADHD. Shortly after this issue, Concerta was released, and was approved for the treatment of ADHD.

The medications currently available in Japan for ADHD include: Concerta (OROS Methylphenidate) and Strattera (Atomoxetine).

These medicines are approved to treat ADHD from 6-18 years old.

Doctors are not allowed to prescribe the medication to anyone younger than 6 years old, and they are only allowed to prescribe ADHD medication to anyone over 18 years old if they started the medication prior to their 18th birthday. In other words, at the current time, if someone is diagnosed with Adult ADHD, and did not start medication before their 18th birthday, they would not be allowed to take an ADHD medication. I do understand that at least one of the companies which produces ADHD medication in Japan is applying for an adult indication for ADHD. If and when this is approved, it would make it easier for patients who get diagnosed with adult ADHD to receive medication for their condition.

For a published scientific article looking at the use of medications for ADHD in Japan, please view this article.

Japanese ADHD Specialists:

When I presented in Tokyo, I presented at a national ADHD meeting. There were many Japanese presenters at the meeting (which I could understand thanks to the translators). I was very impressed by the caliber of their presentations, and the wisdom and insight they shared. I have attended ADHD meetings in Canada, USA and Europe, and while all of the presentations in Tokyo were very good, there were a couple of presentations ranked in the top presentations that I’ve seen. The Japanese Psychiatrists and Pediatricians are very well trained, intelligent, they conduct great research, and they care for their patients deeply.

Prevalence of ADHD in Japan:

The prevalence of ADHD in Japan is relatively understudied. Yoshimasu published in 2006 that regarding ADHD in Japan (and Eastern countries): “the epidemiological evidence including data for incidence, prevalence, gender differences, and etiology remain insufficient.”

When it comes to the number of patients diagnosed with ADHD and the number receiving medication, my sense is that there are significantly fewer in Japan (based on population) compared to the United States or Canada. While I have no solid research upon which to base this opinion, here’s how my logic goes (from my Canadian perspective):

  • Japan has a population of approximately 135 million people; Canada has a population of approximately 35 million people
  • Japan has approximately 500 Child Psychiatrists; Canada has approximately 500 Child Psychiatrists
  • Japan has approximately 2500 Pediatricians who treat ADHD; Canada has approximately 2500 Pediatricians who treat ADHD

In other words – for the size of the population, there is an equally sized ‘work force’ of medical specialists who assess and treat ADHD. While I don’t know the budgets of mental health treatment programs (i.e. how much money is invested in psychological treatments), based on my logic above, I suspect that overall fewer patients in Japan (based as a percentage of the population) are identified with ADHD and receive help for it than are in Canada.

Hopefully these insights and opinions are helpful to you. Please share any comments below.

Before wrapping up, I’d like to share some of my personal experiences traveling in Japan.

My Personal Experiences Traveling in Japan:

I had so many great experiences while in Japan, even though it was a very busy trip (I was there for 6 days, and I had 6 presentations in 4 cities). I hardly had time to get accustomed to the time difference, so I was always some variant of tired while I was there (except for when I was presenting, because as the saying goes: “The show must go on!”). Here are a few experiences which I enjoyed:

Grateful for the translators:

I was fortunate while I was in Japan to have two excellent medical translators. They did real time translation during my presentation, so that doctors could listen to my presentation in Japanese on headphones while I presented in English. When participants asked questions, I would listen to the question in English on headphones, while they were asking in Japanese. While most doctors could speak some English, there were few who could talk about medical issues comfortably in English (and their English was always better than my Japanese!).

When traveling between cities, I was fortunate enough to have a guide to get me to the train, or airport. Because I don’t speak or read Japanese, it is very hard to get around without help, because one can’t even read a street sign! And while many people speak some English, it is hard to get around without speaking Japanese.

Excellent Train System:

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Dr. Kenny and the Bullet Train in Tokyo

Japan has an excellent train system. It runs like clockwork, and the trains are local, express (to an adjacent city), and there are of course the “Bullet Trains”. I did take the Bullet Train from Tokyo to Nagoya. It went approximately 160 km/h, and it was smooth and comfortable. On my last day in Japan, I was supposed to take the Bullet Train from Osaka to Tokyo (so that I could go to Narita Airport to fly home), however there had been an accident earlier, and the bullet train was significantly delayed. The message we were told was that someone had slipped off the platform when the bullet train was passing through a station, so the train was not running. While it was explained as an accident, one of the psychiatrists I had spoken to expressed concerns about the high suicide rate in Japan, and how many people jump in front of trains as their method of committing suicide. While I will never know what happened to that person that day, I was certainly concerned for that person, and their family. In the end, the travel agent found me an alternate way of getting to Tokyo (via a short flight), and I got to Narita airport earlier than I would have otherwise. Interestingly, when I had no ability whatsoever to contribute to the solution of the issue, I had a surprising calm about the fact that I could potentially miss my flight. If I were in the English speaking world, I wouldn’t have had a travel agent with me, and I would have had to figure it out, or get the right help to figure it out – and in that case, I certainly would have worried more.

Expensive Taxi Ride: One of the first things I noticed when I got to Japan was the fact that the airports are quite a distance from the cities. Narita International airport is quite a drive from Tokyo, and when I arrived on a Friday afternoon, it took around 2 hours to get there. The bill for the taxi ride? The equivalent of $300! The message here is this: when you go to visit Tokyo on holidays – make sure to take the train from Narita Airport into Tokyo. It’ll probably be faster, and it will cost a lot less.

JapanTrip 21 of 333 150x150 ADHD in Japan: A Personal Perspective

Fresh Tuna in Tsu City

Amazing Sushi: Need I say more? As a sushi lover, I had fantastic fresh sushi in Japan. I was able to go to two different local restaurants (one in Tokyo and one in Tsu City), and the food was amazing. When I say ‘local restaurants’, I mean restaurants which aren’t tourist locations, but rather restaurants where real Japanese people eat. That’s how I love to get great food when traveling, and I loved it!

Tech Tourism: When I had time to tour in Tokyo, I went to the beautiful Asakusa temple, and then the day was getting late, and things were closing. When I was asking my guide about the different options we had, I chose to go to Ginza (a part of Tokyo), where the Sony showroom is. As a bit of a ‘tech geek’, I really enjoyed seeing the Sony showroom, which included several pieces of technology which aren’t in North America yet. I then went to ‘Bic Camera’, which was like a huge department store, with floors and floors of electronics. Although I loved seeing these great technology stores (and I didn’t spend too much), I must admit that I feel pretty geeky for visiting the tech stores in Tokyo icon smile ADHD in Japan: A Personal Perspective

Wonderful People: While in Japan, I met many smart, educated, warm, caring and humble people. While I was only there a short time, I met some great medical colleagues, and made at least one good friend that I will keep in touch with.

Japan is a fascinating and complex country, and this trip has really piqued my curiosity. I look forward to my next opportunity to go back to the ‘land of the rising sun’, to experience more of what Japan has to offer.

Final Thoughts:

If you are going to travel to Japan, and you take medication for ADHD, please be very mindful of the Japanese rules and laws for stimulant medication. In a future post, I will share the current rules and restrictions (hint – you can’t bring all stimulant medications into Japan…)

Best,

Dr. Kenny

Here are some more of my pictures from Japan:

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Strattera Doesn’t Work for 5 and 6 Year Olds

A recent study was published looking at whether Atomoxetine (Strattera) was helpful for 5 and 6 year olds with ADHD. The researchers found, after an 8 week double blind placebo controlled randomized trial that although there was some benefit, most patients still had clinically relevant symptoms of ADHD, even if they were on Strattera.

You can read a summary of the study here.

This suggests that in this age range, Strattera is not a great treatment for ADHD.

That said, if your child is 5 or 6, talk to your doctor about the treatment options which may help.

Best,

Dr. Kenny

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Generic Strattera in Canada

Updated February 2, 2011

There have been several articles about generic medicines on this blog – many of which have generated significant discussion amongst this blog’s readers. All of the previous articles have been about generic stimulant medicine.
This is the first article about a generic non-stimulant – i.e. Strattera.

In Canada, there was a court decision made in mid October 2010 which paved the way for a generic Strattera (atomoxetine) to be made. A Canadian court invalidated the Eli Lilly patent on the medication atomoxetine for ADHD. This decision has given the generic company Teva-Novopharm the ability to create a generic Strattera in Canada. If you are interested in the details of the legal decision – you can read a summary of it here.

As of the time of this post – i.e. early January 2011 – a generic strattera has not yet come to market in Canada. I can only speculate as to why it has taken so long, as generally a company has the generic product available approximately 6 weeks after a legal decision. Maybe there are manufacturing issues which are causing delays… or maybe there are other factors that I am not even considering.

What does this mean?

At this time (February 2011) there is still no generic Strattera available in Canada. Eli Lilly is still providing samples of its product Strattera to doctor’s offices. They have some sales people and support staff still supporting ADHD/Strattera.  There is still a compassionate program (for people who couldn’t afford the medication), though I’m told that it is currently full – but your doctor could apply for you anyway.

Will the generic work well?

This is a question that I don’t know the answer to. We will have to wait and see. Strattera does not have a time release mechanism in it (like Concerta does) which may mean that the generic will be OK. But it is too early to tell.

Once I hear that the generic Strattera is out – I will be sure to update this blog post, and I welcome any comments from your experiences with generic Strattera.

Best,

Dr. Kenny

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ADHD Medication: $4.2 Billion?

A recent news release came out sharing that the global market for ADD/ADHD medications is expected to reach $4.2 Billion (with a ‘B)  worldwide by 2015. It is projected to go up to $3.3 Billion by 2012.

Whenever I see statistics like this, I find myself having a mixed reaction.

On the one hand, I know that there are studies clearly establishing that there are more people who have ADHD and have not been diagnosed and treated, than people who have it and have been diagnosed and treated. So – seeing that the numbers will be up for pharma companies means that there is more awareness and people are getting a diagnosis and the help that they need.

On the other hand – these types of data can seem quite concerning. How many pills are there in $4.2 billion dollars of income? How many people are taking ‘mind altering medication’? That is certainly what the detractors from ADHD will say. Despite the validity of the diagnosis of ADHD, many still question it, and feel that it is not a valid diagnosis. And when they read this type of statistic, they conclude that ADHD really just a fabrication of the pharmaceutical companies to sell more medicine.

All in all, my perspective is this: There are a lot of studies (I mean a LOT) which show that medications work very well for ADD/ADHD. There are a LOT of studies showing the safety of the medication. There are also studies showing that medicines work best when they are part of a combination treatment. People taking medicines is not wrong, or a problem – in my opinion. The only time I see medications for ADHD as a problem is when people haven’t received a proper assessment and diagnosis – and then they are taking ADHD medication when they may not actually need it. If you (or your son/daughter) is taking ADD/ADHD medication after a thorough assessment, and it is being monitored by a doctor, then it is safe, and hopefully quite helpful.

Of course, the other benefit to the increase of prescriptions, is that likely this means that a lot more people are being diagnosed. Hopefully many of the adults with ADHD who thus far have had trouble getting the proper diagnosis and treatment.

So, here’s my question for you: when you see numbers like that – does it freak you out? Are you OK with it? Do you think it fuels the ADHD detractors?

Please share your opinion in the comments below.

Best,

Dr. Kenny

p.s. my goal is to provide information to people to make the best healthcare decisions they can make at the time they need to. That is why I have created some products on using ADHD medication safely and effectively, as well as some products on alternatives for ADHD. You can click through to those sites to learn more.

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Price of ADHD Medication: A Concerning Trend

As the economy’s downturn is affecting businesses and families alike – it seems that Big Pharma has a plan to keep themselves thriving in this economy.

Quite simply: Raise prices.

A news report shares that Big Pharma are raising their prices to improve their income. Included in the example is Eli Lilly’s Strattera – a non-stimulant medication for ADHD.

I’m not sure if the same thing is happening with other ADHD medications, which are manufactured by other companies.

This is a very concerning trend – especially as people may be under-insured, or uninsured. The medication costs are often prohibitive – and if one needs the medication to survive at work and to keep one’s income, this can be quite a bind.

What has your experience been? Have the costs of your prescription gone up?

Please share your comments below.

** As further explanation – the information above refers to prices in the US. I have recently published two articles showing that the trend in Canada is that in fact the prices are coming down – particularly for Strattera and Adderall XR. You can read more details here: Strattera Price Drop in Canada, and Adderall XR Price Drop in Canada.

Best,

Dr. Kenny

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ADHD Medication: Strattera Funded in New Zealand

It has just been reported that PHARMAC will be funding Strattera in New Zealand.

Strattera is also known as Atomoxetine – and is a non-stimulant for the treatment of ADHD.

Pharmac funding of Strattera will be `second line`, meaning that they will fund it if both of the stimulant medicines (i.e. ritalin and dexedrine) are not effective for ADHD for the individual, or cause significant side effects.

While I am happy for the `Kiwis`to get access to this new medicine with funding, the set up may actually make it harder for people to get the benefits of Strattera.

Why?

Basically, when people have failed two medications for ADHD already – by definition, they are a harder to treat population. And then they are less likely to respond to another medicine. Research suggests that around 70-75% of treatment naive patients respond to Strattera, whereas only 50-55% of patients who have failed other treatment respond to Strattera.

That said – this is a great first step for PHARMAC, and it will improve treatment of ADHD in New Zealand. That said – I do hope they move to a model where Strattera will be offered first line – so that doctors and patients will have the choice to use this new medication when they think that it suits the patient best.

You can read a news report on this here.

Please share your thoughts below.

Best,

Dr. Kenny

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The Dollars and Cents of ADHD

A press release just came out today – publicizing a report which is available for purchase about the nature of the pharmaceutical market in ADHD. The press release documents that the ADHD market is worth $3.85 billion per year, and will have a compound annual growth rate of 1.2% over the next 10 years. They document that the adult ADHD ‘market’ is largely untapped, and they predict that it will likely be twice as big as the pediatric ADHD market.

I have to say that I always have a mixed response when I read statistics like this.

On the negative side – this type of data makes it seems that the pharmaceutical companies are just trying to make sure that more prescriptions are written, and they see people with ADHD as just consumers of their drug and ‘dollars and cents’. Additionally, these data help to fuel the ‘ADHD nay-sayers’ to talk about how ‘over treated’ and ‘over medicated’ ADHD is. (I can hear them saying – ‘almost $4 billion dollars of drugs sold per year???’).

On the other side – this type of just report documents facts…
It’s been documented that it costs over $1 billion USD to bring a new medicine to market. The fact that there is a profit in the ADHD market – and an opportunity for companies to expand sales in the future – means that there will be more research and thus more new treatments introduced in the coming years.

This is ultimately good for people with ADD or ADHD.
New treatment options coming out in the future is a good thing…

In summary – although this type of statistic can be shocking to some – I believe it is important to know that it means that the pharma companies will be willing to invest new monies into ADHD research and treatments.

The danger here is how this statistic can be sensationalized, and how people can get too fixed on the ‘medication only’ treatment of ADHD.

Please remember that the best approach to treatment of ADHD is multimodal – meaning including medication with non-medication approaches (including behavioral therapy, parenting supports, academic/occupational support, coaching, alternative approaches, etc.).

To read a special report that I wrote about ADHD Medication, please visit: Medication Mastery.

Please share your thoughts in the comments section below.

Dr. Kenny

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