Research

Importance  The US has faced a nationwide shortage of attention-deficit/hyperactivity disorder (ADHD) medications since 2022, yet the underlying causes remain unclear. Public debate has largely centered on prescribing trends and Drug Enforcement Administration (DEA) quotas, although evidence suggests that quotas were not binding. A sound policy response requires a clear understanding of the drivers behind the shortage.

Objective  To examine descriptive evidence on the potential causes of the shortage.

Setting and Design  In this economic evaluation, we use time series data (2015-2025) from multiple sources, such as Symphony Health and the DEA’s Automation of Reports and Consolidated Orders System (ARCOS) summary reports, to characterize US production, consumption, and trade of amphetamine-based and other stimulants, including manufacturer-level production volumes, before and during the shortage period.

Findings  The sharp, simultaneous production cutbacks across several medium-sized and smaller manufacturers in late 2022 and early 2023 coincided with a steep contraction in US imports of raw amphetamines and more modest declines in phenylacetone, a key precursor.

Conclusions and Relevance  These patterns align with manufacturers’ reports to the US Food and Drug Administration citing a shortage of the active ingredient as the cause of backorders. More broadly, this economic evaluation reframes the discussion of ADHD medication shortages beyond DEA quotas, highlighting the vulnerability of US pharmaceutical manufacturing to international supply chain disruptions and underscoring the need for policies that strengthen supply chain resilience.

Doctors often treat similar patients differently, which affects health outcomes and medical spending. We assess the recent literature on doctor decision-making through the lens of a model that incorporates diagnostic and procedural skills, beliefs, incentives, and differences in patient pools. Decision-making is affected by beliefs, training, experience, peer effects, financial incentives, and time constraints. Interventions to improve decision-making include providing information, guidelines, and technologies like electronic medical records and algorithmic decision tools. Economists have made progress in understanding doctor decision-making, but applications of that knowledge to improving health care are still limited.

Many mental health disorders start in adolescence, and appropriate initial treatment may improve trajectories. But what is appropriate treatment? We use a large national database of insurance claims to examine the impact of initial mental health treatment on the outcomes of adolescent children over the next 2 years, where treatment is either consistent with US Food and Drug Administration guidelines, consistent with looser guidelines published by professional societies (gray area prescribing), or inconsistent with any guidelines (red-flag prescribing). We find that red-flag prescribing increases self-harm, use of emergency rooms, and health care costs, suggesting that treatment guidelines effectively scale up good treatment in practice.

Noncarceral conviction is a common outcome of criminal court cases: for every person incarcerated, there are approximately three who were recently convicted but not sentenced to prison or jail. We extend the binary-treatment judge IV framework to settings with multiple treatments and use it to study the consequences of noncarceral conviction. We outline assumptions under which widely used 2SLS regressions recover margin-specific treatment effects, relate these assumptions to models of judge decision-making, and derive an expression that provides intuition about the direction and magnitude of asymptotic bias when a key assumption on judge decision-making is not met. We find that noncarceral conviction (relative to dismissal) leads to a large and long-lasting increase in recidivism for felony defendants in Virginia. In contrast, incarceration (relative to noncarceral conviction) leads to a short-run reduction in recidivism, consistent with incapacitation. Our empirical results suggest that noncarceral felony conviction is an important and overlooked driver of recidivism.

We estimate the labor market impacts of Brazil’s 1993 outsourcing legalization using North-South variation in pre-legalization court permissiveness, and comparing security guards to less affected occupations. We find that outsourcing legalization persistently reallocated jobs from older incumbent guards to younger entrants. Total employment of guards and their entry from informality persistently increased, while average demographic-adjusted wages remained constant. Meanwhile, a wave of occupational layoffs displaced some incumbent guards from high-wage firms. The evidence suggests that the rise of non-core activity outsourcing reduced labor market frictions, facilitated by firm-level economies of scale in human resources and spillovers to non-adopting firms.