Hello again! It’s been a while. Yes, despite my best intentions, I neglected this Substack. Suffice it to say, I’ve had a hectic and stressful few months, and this project fell between the cracks.
But I’m back, and I’m angry. The BBC just published an investigation into UK-based private providers of ADHD medicine, and it’s so flawed and so lacking in nuance, I feel compelled to comment.
(Side note: I wrote this over my lunch break. Please forgive any spelling mistakes. I’ll edit/polish later, but for the sake of timeliness, I wanted to get this newsletter out there.)
The article, from Panorama reporter Rory Carson, contrasts three private ADHD clinics (ADHD360, Harley Psychologists, and the Glasgow-based ADHD Direct), who all diagnosed the reporter with the condition. Carson also saw an NHS psychiatrist, who didn’t.
The unspoken inference is that these providers are “pill mills,” handing over diagnoses and prescriptions to anyone that darkens their door.
Except things are way more complicated than that. And it’s this complexity that Carson completely ignores.
An ADHD Diagnosis is Subjective
Okay, so how did four different healthcare providers reach two different conclusions? Something Carson failed to emphasize in the piece is that any ADHD diagnosis is based on a subjective interpretation of the facts presented.
There’s no blood test for ADHD. Inattentiveness doesn’t show up on an MRI scan like a tumor. To diagnose the condition, the psychiatrist (or another healthcare provider) asks about your childhood, your personal life, and your working life. They may speak to your friends, family, or spouse.
Ultimately, two (or four!) people can examine the same information and come to wildly divergent conclusions.
Carson Compared Apples and Oranges
This bit is simple. The three clinics used by Carson didn’t know he was an undercover reporter. The NHS psychiatrist, the Leeds-based Dr Mike Smith, did. To quote:
“Things were very different when I met Dr Mike Smith, a consultant psychiatrist who leads a specialist adult ADHD service in the NHS. I told him about my investigation and he said he also had concerns about how some private providers were operating. He agreed to show me how an assessment should be carried out.”
Okay. So the one dissenting voice is someone who already understood Carson’s skepticism of the private ADHD healthcare sector and understood the appointment was primarily for the purpose of an investigation, rather than to address actual clinical need.
It’s not hard to see how, having known the context behind the appointment, Dr. Smith’s conclusions would have been biased. And that’s not saying anything about his clinical ability, professionalism, or conduct. That’s just human nature.
Carson overlooks why private ADHD providers exist
NHS waiting lists for adult ADHD services vary nationwide, but they’re long.
In Liverpool, where I live, it’s about five years. Other regions have waiting lists of just one or two years, but they’re often the exception, not the rule.
ADHD is a debilitating condition. People with the condition are more likely to suffer relationship breakdown, substance abuse, and unemployment. A diagnosis — and the medication it provides — offers relief, stability, and hope.
That’s why people pay to go private. Because they can’t bear living with the condition any longer and need help.
Admittedly, Carson mentions the waiting lists in passing, but the subject doesn’t really get the attention it deserves. This is the why behind the rise of companies like ADHD360— and it’s quickly glossed over as though it doesn’t matter.
And he barely mentions the debilitating impact of ADHD. I know people who, before their diagnoses, spiraled through a cycle of joblessness, debt, impulsivity, and hopelessness. It was only when they started treatment that they could get their lives back on track.
Carson’s description of ADHD medication verges on scaremongering
After being diagnosed with ADHD by Harley Psychologists, Carson was offered an unspecified stimulant, which he describes as a “powerful controlled drug” that “can cause insomnia, elevated heart rate and high blood pressure - and in rare cases panic attacks, psychosis and seizures.”
Again, I’d love some nuance here. There are a lot of ADHD medications, including stimulants and non-stimulants (like Strattera). Even within the stimulant camp, there’s some variation between the side effects and the likelihood they’ll manifest.
Similarly, he doesn’t mention the fact that anyone starting ADHD treatment goes through a process of titration, where doses are gradually increased until the patient starts to feel the optimal effect. The practitioner may also change medications if one isn’t having the desired effect, or is producing negative side-effects.
Carson also mentions that “there was also no mention of other treatments, such as talking therapy.”
Admittedly, talking therapy (particularly CBT) is an effective treatment for ADHD, especially when combined with medication.
Still, medication is the first line of treatment for a few good reasons: 1.) You don’t have to wait to start treatment, 2.) it has an immediate effect, and 3.) even in the private sector, there’s a massive shortage of mental health practitioners.
This context was conspicuously absent from the piece.
Carson is depressingly uncurious about why adult ADHD diagnoses are increasingly common
One former Harley Psychologists patient mentioned in the piece claims she became convinced she had ADHD after seeing an Instagram post. Carson cites a “common refrain” from critics of the private ADHD healthcare sector: "If you're willing to pay for an assessment, you'll get a diagnosis.”
Is there any evidence to back up the implied assertion that these providers are “pill mills” other than a blind quote attributed to a disparate group of people?
No. Of course not.
There’s a consensus among psychiatrists that the UK under-diagnoses ADHD. It’s estimated that between five and seven percent of children have the condition, but only 0.2-0.9 percent actually get a diagnosis.
Those kids become adults, and when they start to experience troubles in their personal and professional lives, they ask why. They go online and read stories about people with the condition who obtained treatment and saw their quality of life dramatically improve. And then they want it for themselves.
I know this because it happened to me.
I was in my early twenties, miserable and having failed at god-knows-how-many jobs and relationships. I was living in my childhood bedroom and feeling like flotsam.
One day, a video popped up on my Facebook news feed. It was from a MountainWest RubyConf, a conference centered around the Ruby programming language. The speaker, Greg Bauges, spoke passionately for thirty minutes about his life with undiagnosed ADHD and bipolar disorder, and his journey to treatment. Suddenly, things about my life began to make sense. Something clicked.
Several years later, I attended a private clinic and had my suspicions confirmed. I only wish I had gone sooner.
Since starting my Substack, I’ve had people reach out and say that my writing prompted them to seek help. It’s the best feedback I’ve ever received.
The Internet is an integral part of our lives. We live in a time when people are increasingly candid about neurodivergence and mental health. And that candor is good!
Carson’s failure to do his job might actually hurt people
For the sake of fairness, Carson highlighted a few areas of concern. One clinic threatened to refer someone who posted a negative review to its legal department — although the story doesn’t actually say whether any action was taken, or if they sent a letter before action.
One clinician was described as “slouched on a sofa wearing a tracksuit top” and not paying full attention to the call. Again, that isn’t good. But it also isn’t what this story is about.
But the core thesis of Carson’s piece is that misdiagnosis is widespread within the private ADHD healthcare sector, and the biggest providers are recklessly handing out diagnoses and medication to those who don’t need it. And that allegation is — and remains — unproven.
As a general rule, I don’t like shitting on other journalists, partly because I am one and I know how things work. It’s a hard job. Word counts and crushing deadlines make it hard to capture a story’s every detail and subtlety. This is something fellow hacks innately understand and outsiders seldom do.
Still, this was bad. It’s not so much that Carson missed a few details, but rather the piece was utterly stripped of any nuance, context, or balance.
At the time of writing, Carson’s article is on the front page of the BBC website. It will also be broadcast on May 15 by BBC Panorama. And I worry that it’ll deter people from actually getting the treatment they need to live full, successful, and happy lives.
Brits are great at minimizing their own health concerns. It’s that stiff-upper-lip thing. Keep calm and carry on. “I thought I had ADHD, but then again, maybe not.”
Most of all, I worry it’ll provoke the government into taking a knee-jerk action against the private ADHD healthcare sector, as we saw in the US with Cerebral, which no longer prescribes Adderall and other controlled medications for new patients.
Don’t get me wrong. From what I’ve read, Cerebral was a dysfunctional company, and it failed to diagnose ADHD with the level of rigor required. But it also made ADHD treatment accessible, particularly for low-income people. It was a lifesaver for many, and this point is seldom recognized.
I genuinely fear that shallow, half-baked reporting like Carson’s will create the conditions for a moral panic that will inevitably result in adult ADHD treatment inaccessible for many. We have a government that’s in terminal decline and desperately looking for new bogeymen to distract from its abysmal record on healthcare, the economy, and education.
ADHD is widely misunderstood, and its effects are often dismissed as character flaws rather than a medical condition needing treatment. And it’s not hard to imagine how a crackdown on private ADHD healthcare providers would play out in the Daily Mail.
As always, if you have any comments, feel free to drop me a tweet or an email. Or leave a comment below. And if you’re new to my newsletter, please consider subscribing.
Hi,
I agree with your conclusions about R Carson's poor journalism. There were a number of aspects that were manipulated and edited for a reason to show these clinics in a bad light.
However, there is one very important factor that hasn't been mentioned in any of the comments published on the Internet after broadcasting the BBC material: ethics. How ethical is it to show the full names and faces of the staff of two of the three clinics? What purpose does it serve? Why did the two nurses from the second clinic have their faces blurred and their voices altered? isn't that strange? Or maybe it isn't. Perhaps the fact that the three exposed people look like non-native British, and they likely look like non-white people (at least the two men)? Isn't this racist and xenophobic behaviour shown by Carson? What about endangering these people by giving their full names and addresses where they can be found? Will the BBC take responsibility if something happens? Will the BBC take responsibility for the trauma caused by the defamatory publication? What about giving the exposed people a chance to defend themselves? Carson didn't bother to be fair. There was no mention of the fact that the problems with ADHD diagnosis come from the NHS, which is not up to the task. Are they doing any better? Do they really spend over three hours with each patient, testing for every possible symptom of the condition? Of course they don't. Queues can be long, 5 years waiting time... I'd say shame on the BBC for supporting such bad journalism.