Cite this article as:
Richard M. Scheffler, Stephen P. Hinshaw, Sepideh Modrek and Peter Levine
The Global Market For ADHD Medications
, 26, no.2 (2007):450-457
The online version of this article, along with updated information and services, is
For Reprints, Links & Permissions:
is published monthly by Project HOPE at 7500 Old Georgetown Road, Suite 600,
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on August 6, 2013
The Global Market For ADHD Medications
The United States is an outlier among developed countries in its highusage rates of these medications among children.
by Richard M. Scheffler, Stephen P. Hinshaw, Sepideh Modrek, and
ABSTRACT: Little is known about the global use and cost of medications for attention defi-
cit hyperactivity disorder (ADHD). Global use of ADHD medications rose threefold from
1993 through 2003, whereas global spending (U.S. $2.4 billion in 2003) rose ninefold, ad-
justing for inflation. Per capita gross domestic product (GDP) robustly predicted use across
countries, but the United States, Canada, and Australia showed significantly higher-than-
predicted use. Use and spending grew in both developed and developing countries, but
spending growth was concentrated in developed countries, which adopted more costly,
long-acting formulations. Promoting optimal prescription and monitoring should be a prior-
ity. [Health Affairs
26, no. 2 (2007): 450–457; 10.1377/hlthaff.26.2.450]
disorder (ADHD), a psychiatric condi-
ADHD are lacking, a problem shared with
tion first evident in childhood, is the
most other psychiatric conditions. Guidelines
subject of great clinical interest and strong
for proper diagnosis must be followed, so that
scientific investigation.1 The prevalence of
disorders with similar symptoms (such as con-
ADHD is 5–8 percent of U.S. children and ad-
duct disorder or bipolar disorder) do not re-
olescents, and its impairments are likely to
ceive inappropriate stimulant treatment.5 Sec-
persist into adolescence and adulthood.2 A
ond, prescription rates of stimulants (and
syndrome with strong neurobiological ori-
other psychotropic medications) have greatly
gins, ADHD has major importance for public
increased, at least in the United States, even
health, given the marked academic, social, fa-
for preschoolers.6 About half of U.S. children
milial, and accidental injury–related impair-
and adolescents diagnosed with ADHD re-
ments with which it is associated.3
ceive stimulant medications or related agents.7
First used for youth in the 1930s, psycho-
Third, unintended side effects may accompany
stimulant medications enhance dopaminergic
stimulant use. Most are mild, but public
and noradrenergic neurotransmission and
health concerns have arisen about the poten-
provide symptom improvement in the clear
tial for negative cardiovascular effects and sui-
majority of people who receive them.4 Several
cidal thoughts.8 Fourth, questions abound
Richard Scheffler ([email protected]) is director of the Nicholas C. Petris Center on Health Care Markets andConsumer Welfare, and Distinguished Professor of Health Economics and Public Policy at the University ofCalifornia, Berkeley. Stephen Hinshaw is professor and chair, Department of Psychology, at that university.
Sepideh Modrek is an Agency for Healthcare Research and Quality Pre-Doctoral Fellow and a graduate student inhealth services and policy analysis at the university. Peter Levine is a physician in the Department of Pediatrics,Kaiser Permanente Walnut Creek Medical Center, in Walnut Creek, California.
DOI 10.1377/hlthaff.26.2.450 2007 Project HOPE–The People-to-People Health Foundation, Inc.
on August 6, 2013
about the potential for "diversion" of prescrip-
amphetamine, or other stimulant (Exhibit 1).
tion stimulants to people without ADHD, re-
To analyze changes in medication mix, we
lated to improvement of study skills and pos-
then generated a three-level categorization of
sible euphoriant effects.9
short-acting stimulants, long-acting medica-
Since the 1960s, methylphenidate and dex-
tions that received approval from the Food and
troamphetamine have been the mainstays of
Drug Administration (FDA) during the study
stimulant prescriptions for ADHD. New for-
period, and other long-acting medications. As
mulations, as well as efficacious nonstimu-
a proxy for dose, IMS Health calibrated each
lants, have taken up an increasingly large U.S.
product form into a common metric known as
market share since the late 1990s.10 Given the
a standard unit (SU). For example, one stan-
increasing recognition that ADHD is a prob-
dard unit is equivalent to a 5 mg tablet or 5 ml
lem of worldwide scope, diffusion of ADHD
of a liquid.
medications outside the United States may
To compare countries' usage, we created a
well be occurring, but the extent to which
usage per capita measure (SU per child ages 5–
global use includes these newer and more
19) to examine the relationship between use of
costly formulations is unknown.11
ADHD medications and national income for
Countries with different diagnostic tradi-
each country that is a member of the Organiza-
tions, such as the United Kingdom, have had
tion for Economic Cooperation and Develop-
lower prevalence rates than the United
ment (OECD). We estimated a fixed-effects
States.12 However, ADHD appears in multiple
model to establish the relationship between
nations and cultures at similar prevalence
per capita (ages 5–19) use and per capita
rates.13 Less well documented are international
GDP.14 This method estimates parameters in
treatment patterns, including rates of use and
panel data, which controls for variability
associated costs. Our objectives are to (1) de-
across countries and over time.15
scribe global trends in ADHD-related medica-tion use, the types of medications used, and
medication spending over the past decade; (2)
In 1993, thirty-one countries had adopted
make a preliminary determination of the fac-
the use of ADHD medications; by 2003, the
tors that explain diffusion of ADHD medica-
number had grown to fifty-five.16 Our analysis
tions globally; and (3) discuss relevant policy
aggregated data from individual countries
from the year of adoption into a global sum.
Because the United States is the single largest
Study Data And Methods
market, we also show its use, which consti-
We used the IMS Health MIDAS database
tutes 83–90 percent of total market share (by
to analyze trends in the global market for
ADHD medications from 1993 to 2003. We
n Global utilization. The usage of ADHD
classified ADHD medications as those in the
medications increased 274 percent during the
"ATC=N6B Psychostimulants" category, along
study period (Exhibit 2).17 From 1993 to 2000,
with the nonamphetaminelike stimulant mo-
global volume increased steadily (13.2 percent
dafinil (Provigil, Cephalon) and the nonstim-
per year); from 2000 to 2003, growth acceler-
ulant atomoxetine HCL (Strattera, Lilly). Each
ated to 16.8 percent per year.18 The U.S. share of
medication (name brand and generic) was
the global market declined from 86.8 percent
classified into one of four categories, along the
in 1993 to 83.1 percent in 2003. A more detailed
dimensions of (1) stimulant versus nonstimu-
analysis (not shown) reveals marked variation
lant medications and (2) long-acting (formu-
by country. Low-use countries exhibited
lations that remain active for at least eight
growth rates as high as 46 percent per year,
hours) versus short-acting (fewer than eight
whereas moderate-use countries had growth
hours). We further classified stimulants by ac-
rates of nearly 20 percent per year. If these
tive pharmacologic agent: methylphenidate,
rates continue, the U.S. market share should
on August 6, 2013
EXHIBIT 1Categories Of Attention Deficit Hyperactivity Disorder (ADHD) Medications
(fewer than eight hours)
(eight hours or more)
SOURCE: Authors' classification scheme, based on the pharmacologic literature.
NOTES: These medication names are those used commonly in the United States. The equivalent preparations were
determined from other countries.
a Long-acting medications approved by the Food and Drug Administration (FDA) after January 1993.
b Other long-acting medications.
continue to fall.
fixed-effects model.20 Exhibit 3 illustrates the
We then analyzed the relationship between
relationship between per capita (ages 5–19)
per capita utilization of ADHD medications
use and per capita GDP. Data points on or near
and the per capita GDP of the OECD coun-
the diagonal line show countries using these
tries, given that income is a well-known pre-
medications at levels predicted by their per ca-
dictor of health care spending.19 Use of ADHD
pita GDP. The United States uses them at a
medications is positively related to per capita
level that is about four times higher than
GDP, with a p
value of less than 0.001 using a
would be predicted by income alone, holding
EXHIBIT 2U.S. And Global Volume Of Attention Deficit Hyperactivity Disorder (ADHD)Medications, 1993–2003
SOURCE: MIDAS database, IMS Health, 1993–2003.
NOTES: Volume adjusted to generate dosage equivalence between short- and long-acting medications. Long-acting medicationsare weighted twofold over short-acting medications. SU is standard units.
on August 6, 2013
EXHIBIT 3Predicted And Actual Usage Of Attention Deficit Hyperactivity Disorder (ADHD)Medications In OECD Countries, By Income, 2003
SU per child (ages 5–19)
Per capita GDP, in thousands of U.S.$ PPPs
SOURCE: MIDAS database, IMS Health, 2003.
NOTES: Although the data are shown for a single year, other years look similar in overall patterns; 2003 is the most recent yearfor which data were available. Only twenty-seven of the thirty Organization for Economic Cooperation and Development (OECD)member states are represented; no data were available for Iceland, Denmark, or Slovakia.TUR is Turkey. MEX is Mexico. POL isPoland. HUN is Hungary. CZE is Czech Republic. PRT is Portugal. PRK is South Korea. GRC is Greece. NZL is New Zealand. ESP isSpain. ITA is Italy. DEU is Germany. JPN is Japan. FIN is Finland. FRA is France. SWE is Sweden. BEL is Belgium. GBR is UnitedKingdom. AUS is Australia. NLD is Netherlands. CAN is Canada. AUT is Austria. CHE is Switzerland. IRL is Ireland. NOR is Norway.
USA is United States. LUX is Luxembourg. Where space prohibits labeling each point, abbreviations are as follows: 1 = PRT, GRC,PRK; 2 = FIN, SWE, FRA, JPN; 3 = GBR, BEL. SU is standard units. GDP is gross domestic product. PPP is purchasing power parity.
a Countries have significantly different usage than the predicted at the 95 percent confidence interval.
all country-specific deviations constant. Can-
cent growth rate per year. Other countries
ada and Australia also show higher-than-
showed a slightly slower spending growth rate
expected use. In contrast, Italy, Ireland, Aus-
than the United States—about 21.0 percent
tria, Japan, Sweden, and Finland use less than
per year. A country-by-country analysis re-
predicted by per capita GDP. A country-by-
veals that spending increases were much more
country analysis of the growth rate of use of
pronounced in developed countries.22
ADHD medications over the past four years
n Medication mix. There has been a clear
shows increases in both developed countries
change in the medications used to treat ADHD
and developing countries.21
(Exhibit 5). The volume of short-acting medi-
n Global expenditures. Moving from use
cations plateaued and then steadily decreased
to spending, the global expenses regarding
after 1999, whereas the volume of long-acting
ADHD medications were U.S.$2.4 billion by
formulations increased during the second half
2003, representing a ninefold increase (ad-
of the study period. The timing of this shift is
justed for inflation) since 1993 (Exhibit 4).
related to FDA approval of Concerta (Johnson
From 1993 to 2000, spending grew steadily
and Johnson), a controlled-release form of
(about 17.6 percent per year), but after 2000
methylphenidate, in August 2000. Although
the annual growth rate increased more steeply
the release of this and other relatively costly
to 40.9 percent. This acceleration was largely
long-acting formulations such as Adderall XR
driven by the U.S. market, where newer medi-
(Shire) and Strattera (Lilly) help explain some
cations—primarily longer-acting formula-
of the increase in use, their presence is particu-
tions—became available. The United States
larly related to the large spending increase. Us-
dominates global spending on ADHD medica-
ing the same data set, we found that the in-
tions, making up approximately 92–95 per-
crease in spending for ADHD medications in
cent of the total expenditures, with a 22.6 per-
the U.S. market was attributable mostly to
on August 6, 2013
EXHIBIT 4U.S. And Global Spending On Attention Deficit Hyperactivity Disorder (ADHD)Medications, 1993–2003
SOURCE: MIDAS database, IMS Health, 1993–2003.
NOTES: Spending is deflated to 2003 U.S. dollars using the U.S. Consumer Price Index. Cross-sectional variation from country tocountry was accounted for by IMS Health, which had converted all local currencies to U.S. dollars using purchasing power parity(PPP) methods. SU is standard units.
price increases.23 From 1994 to 2003, U.S. sales
2002, as long-acting formulations were intro-
volume increased 80 percent, while prices in-
duced worldwide. These data suggest that the
creased 285 percent in real dollars. In contrast,
pattern in these countries lags behind that of
in OECD countries sales volumes increased
the United States by several years.
322 percent, while prices rose only 70 percent.
A sampling of prices from Consumer Reports Best
reveals a large differential between
The use of stimulant medications in the
short- and long-acting formulations.24 Beyond
United States has greatly increased during the
the United States (data not shown), the use of
past twenty years.25 Although the increase
short-acting formulations began to plateau in
might be leveling off for children, much con-cern has been raised regarding the potential
EXHIBIT 5Global Volume Of Attention Deficit Hyperactivity Disorder (ADHD) Medications, ByCategory, 1993–2003
SOURCE: MIDAS database, IMS Health, 1993–2003.
NOTE: SU is standard units.
on August 6, 2013
for overdiagnosis of the disorder, the potential
more sharply over the next decade.
for overuse of these medications, and the pos-
Our analysis of ADHD medication use as a
sibility of diversion and abuse, weighed
function of per capita GDP showed that de-
against their important clinical benefits under
spite robust predictions of use from this indi-
conditions of careful diagnosis and treatment
cator of national income, other factors might
monitoring.26 This study has confirmed that
explain variation in use. For example, U.S. cli-
the United States is by far the world's largest
nicians tend to recognize ADHD as a debilitat-
consumer of ADHD medications. Why other
ing disorder.30 Furthermore, changes in the
countries have lagged behind is not well un-
federal special education law (the Individuals
derstood. Advertising in the United States is
with Disabilities Education Act [IDEA]) en-
clearly an important factor; the number of U.S.
acted in 1991 opened up special education ser-
medical specialists who are able to diagnose
vices for children with ADHD, prompting
and treat ADHD is also crucial. Clearly, na-
greater diagnosis.31 Other factors include
tional policies about the purchase of medica-
widespread third-party medication coverage,
tions by the health system—as well as the very
marketing efforts by pharmaceutical firms,
nature of different national health care sys-
and a general increase in the use of all psycho-
tems—are essential factors. It appears that lit-
tropic medications for children.32 Finally, the
tle difference exists in the rates of the disorder
United States has the highest overall drug
between the United States and other coun-
spending per capita among the OECD coun-
tries, although rates of "diagnostic prevalence"
(that is, cases actually diagnosed by clinicians)
Despite major differences from the U.S.
lag well behind true prevalence outside the
health care system and considerable regulation
of pharmaceutical prices, Canada also exhibits
Other countries, however, are beginning to
high usage of ADHD medications.34 This pat-
follow U.S. trends. Over the past decade, use of
tern might be a function of its proximity to the
ADHD medications in non-U.S. OECD coun-
United States, with exposure to U.S. advertise-
tries has increased at rates even greater than
ments and cultural norms. Within other coun-
those in the United States. Furthermore, coun-
tries (such as Sweden and France), strict gov-
tries using the most ADHD medications per
ernmental regulation against the prescription
capita are those with the highest incomes.
of ADHD medications might also explain some
Over the past five years, many developing
of the variation in use.35 For example, in
countries have had yearly growth rates in use
France, use of methylphenidate, the only ap-
and spending that exceed 20 percent.28
proved ADHD medication, requires a hospital-
Although the use of ADHD medications is
initiated prescription from a neurology, psy-
increasing globally, the cost of these medica-
chiatry, or pediatric specialist.36 In the Nether-
tions is escalating even more rapidly. With the
lands, there are lower rates of prescription
advent of longer-acting stimulants and non-
than in the United States, but major increases
stimulant agents, spending for ADHD medica-
of stimulant use became evident in the late
tions has risen dramatically. Note that a
1990s.37 Other potential factors related to dif-
month's supply of generic methylphenidate
ferential use rates include differing diagnostic
taken two or three times per day costs around
criteria for ADHD, the professional training of
U.S.$25, whereas the cost of one month's sup-
physicians and mental health care providers
ply of Concerta 18 mg, taken once a day, is
with respect to ADHD, differences in national
U.S.$109.29 The change to long-acting agents
health care systems, rates of overall pharma-
began in the United States in 2000; other
ceutical spending, perceptions of ADHD by
countries are following the same trend but
parents and teachers, and variation in educa-
with a lag of several years. We can expect that
the already burgeoning global costs for medi-
Understanding determinants of the use of
cation treatment for ADHD will rise even
ADHD medications, their costs, and their po-
on August 6, 2013
tential risks and benefits is now a global issue.
N.J.: Civic Research Institute, 2002), 5-1–5-21.
ADHD clearly involves biological, behavioral,
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This study was funded in part by a grant from the
Ritalin," New York Times,
10 February 2006.
National Institute of Mental Health [1R01
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MH067084-01 MH1 SRV-C (01)]; in part by a grant
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from the Center for Child and Youth Policy, University
stance Use Patterns among Adolescents and
of California, Berkeley; and in part by the Nicholas C.
Young Adults," Journal of Child and Adolescent Psycho-pharmacology
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27. Nigg, What Causes ADHD.
28. See Section C of the online technical appendix,
as in Note 15.
29. "Evaluating Drugs Used to Treat: Attention Defi-
cit Hyperactivity Disorder."
on August 6, 2013
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