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주의력결핍 과잉행동장애 치료의 역사적 재조명 : 약물치료적 접근

Revisiting History of Treatment of Attention Deficit Hyperactivity Disorder : Pharmacologic Approach

이연정|한주희|오수현|반건호|홍민하
대한생물정신의학회 (The Korean Society Of Biological Psychiatry)|2014.05|생물정신의학 (Journal of Korean Society of Biological Psychiatry)|제21권 제2호|pp. 37-48

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ADHD주의력결핍 과잉행동장애역사MedicationHistory암페타민약물MethylphenidateAmphetamine메칠페니데이트아토목세틴Atomoxetine
주제분류정신과학

초록

주의력결핍 과잉행동장애(attention deficit hyperactivity disorder, 이하 ADHD)의 치료율은 빠르게 늘고 있다. 미국에서 부모 대상으로 조사한 자녀들의 ADHD 약물 치료 비율은 2007년 전체 학생 인구 중 4.8%에서 2011년 6.1%로 높아졌으며, 진단받은 아동의 70% 정도는 약물치료를 받고 있다.1) 852711명의 코호트 집단을 대상으로 덴마크에서 시행한 ADHD 약물 투여 비율은 2003년과 2010년 비교시 자폐증, ADHD, 기타정신병에서 모두 약 5배 정도 증가하였다.2) ADHD 진단과 치료에 엄격한 유럽에서도 변화가 있다. 영국에서는 1990년 1년간 처방 건수가 2000건이었으나, 1997년 92000건, 2006년 500000건으로 증가하였다.3) 새로운 질병이므로 새롭게 진단받고 치료받기 시작하는 환자가 늘어나는 것은 당연한 현상이라는 견해도 있으나,4) 약물사용이 폭발적으로 늘어나는 것에 대한 비판의 소리도 늘고 있다. 이러한 논란이 끊이지 않는 이유 중 하나는 약물치료의 타당성과 진단에 대한 의구심이 사라지지 않기 때문이다.5) 즉, 미국정신의학회(American Psychiatric Association)에서 처음으로 정신장애 분류를 위한 the Diagnostic and Statistical Manual of Mental disorders(이하 DSM)-I6) 제작 당시 ADHD 진단의 시발점이 된 minimalbrain dysfunction(이하 MBD)이 포함된 이래, DSM-IIIR7)에서 현재 사용되는 ADHD라는 진단명을 채택하였고,DSM-58)에서는 ADHD를 이전의 소아기 장애에서 ‘신경발달학적 장애’ 범주에 포함시켰다. ADHD의 1차 약물은 중추신경자극제와 비중추신경자극제인 atomoxetine이다.9) 비중추신경자극제인 guanfacine,modafinil, clonidine 등도 사용되고 있으나, Christensen 등10)에 따르면 2004년부터 3년여에 걸쳐 미국 내 60010명의 ADHD환자 약물 사용 분석에서 78.4%의 환자가 중추신경자극제를주치료제로 사용하고 있으며, 치료 지속 여부도 비자극제에 비해 중추신경자극제 사용시 더 좋은 것으로 보고하였다. 처방량이 많은 만큼 약물치료의 적정성에 대한 논란의 중심에는항상 중추신경자극제가 있다. 따라서 본 연구에서는 ADHD의 개념적 변천은 물론, 중추신경자극제 개발 이전과 이후의 치료 역사를 알아봄으로써,ADHD 치료를 둘러싼 논쟁의 적절성에 대해 검토하였다.

Abstract

Besides from medical data, the patients who were previously called as attention disorder, mental instability, moral imbeciles, or moral defectives, can also be identified by exploring literatures and historical figures. In the past, as we can notice from the titles, they were recognized as a ‘moral defect group’. And rather than treating them, separation from the society was the main solution. After the endemic encephalitis from 1917 to late 1920s, however, many survivors suffered from behavioral problems similar to those of the previous ‘moral defect group’ and studies on the relationship between brain damage and behavior problems were started henceforth. After being known as the ‘minimal brain dysfunction’, it was developed into the current attention-deficit/hyperactivity disorder. While the disease concept changed and developed over time, after numerous trials and errors, treatment medication starting from central nervous system stimulants such as amphetamine and methylphenidate is used for treatment in children and adult patients with ADHD, and most recently non-stimulants such as atomoxetine has become the one of the first line treatment options. Although we went through a thorough verification process of the safety and efficacy of the medication by contemplating the historical development process, we believe that adjustment is needed for remaining concerns on medication abuse and slight differences in disease paradigm and therapeutic philosophy depending on cultures.

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