How do different diagnostic criteria, age and gender affect the prevalence of attention deficit hyperactivity disorder in adults? An epidemiological study in a Hungarian community sample

Beyond Attention-Deficit Hyperactivity Disorder: Exploring Psychiatric Comorbidities and Their Neuropsychological Consequences in Adults

Objectives

This study aimed to identify the psychiatric comorbidity status of adult patients diagnosed with attention-deficit hyperactivity disorder (ADHD) and determine the impact of comorbidities on neuropsychological outcomes in ADHD.

Methods

The study participants were 124 adult patients with ADHD. Clinical psychiatric assessments were performed by two boardcertified psychiatrists in accordance with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. All participants were assessed using the Mini-International Neuropsychiatric Interview Plus version 5.0.0 to evaluate comorbidities. After screening, neuropsychological outcomes were assessed using the Comprehensive Attention Test (CAT) and the Korean version of the Wechsler Adult Intelligence Scale, Fourth Edition (K-WAIS-IV).

Results

Mood disorders (38.7%) were the most common comorbidity of ADHD, followed by anxiety (18.5%) and substance use disorders (13.7%). The ADHD with comorbidities group showed worse results on the Perceptual Organization Index and Working Memory Index sections of the K-WAIS than the ADHD-alone group (p=0.015 and p=0.024, respectively). In addition, the presence of comorbidities was associated with worse performance on simple visual commission errors in the CAT tests (p=0.024).

Conclusion

These findings suggest that psychiatric comorbidities are associated with poor neuropsychological outcomes in adult patients with ADHD, highlighting the need to identify comorbidities in these patients.

Gender-based differences in prevalence and effects of ADHD in adults: A systematic review

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder that starts from childhood and lasts through adulthood. Historically thought as male dominant disorder, researches now emphasized that ADHD also effects females equally. Despite the ascending research on gender differences of ADHD, there is little known about its differences in prevalence and effects and there is a dearth of reviews that can draw a firm conclusion especially in adults. Data from the available medical literature published in English language literature of all time was reviewed systematically and tabulated to evaluate the gender-based differences in prevalence and effects of ADHD in adults. The studies revealed gender differences in adult ADHD in prevalence, and effects. Results showed that males have more prevalence as compared to females but females too have a significant presence of disorder. Females were more impaired as compared to men in most of the effects of ADHD like social functioning, time perception, stress tackling and mood disorder. Males were more impaired in working memory and educational functioning as compared to females. The review shows sufficient evidence of gender differences in adult ADHD in prevalence, and effects, that similarity across genders should not be assumed. It is concluded that there are plenty of conflicting evidence regarding gender differences in many areas of adult ADHD research, and to remove such discrepancies, the existing research is the need for more studies on gender differences and similarities in functioning of adults with ADHD.

Atypical resting-state gamma band trajectory in adult attention deficit/hyperactivity disorder

Decreased gamma activity has been reported both in children and adults with attention deficit/hyperactivity disorder (ADHD). However, while ADHD is a lifelong neurodevelopmental disorder, our insight into the associations of spontaneous gamma band activity with age is limited, especially in adults. Therefore, we conducted an explorative study to investigate trajectories of resting gamma activity in adult ADHD patients (N = 42) versus matched healthy controls (N = 59). We investigated the relationship of resting gamma activity (30–48 Hz) with age in four right hemispheric electrode clusters where diminished gamma power in ADHD had previously been demonstrated by our group. We found significant non-linear association between resting gamma power and age in the lower frequency gamma₁ range (30–39 Hz) in ADHD as compared to controls in all investigated locations. Resting gamma₁ increased with age and was significantly lower in ADHD than in control subjects from early adulthood. We found no significant association between gamma activity and age in the gamma₂ range (39–48 Hz). Alterations of gamma band activity might reflect altered cortical network functioning in adult ADHD relative to controls. Our results reveal that abnormal gamma power is present at all ages, highlighting the lifelong nature of ADHD. Nonetheless, longitudinal studies are needed to confirm our results.

Cohort Change in the Prevalence of ADHD Among U.S. Adults: Evidence of a Gender-Specific Historical Period Effect

Objective: To document inter- and intra-cohort changes in adult ADHD and examine whether changes vary by gender. Method: We analyze data from the 2007 and 2012 U.S. National Health Interview Survey. Results: The prevalence of ADHD among adults aged 18 to 64 years increased from 3.41% in 2007 to 4.25% in 2012. As expected, patterns of inter- and intra-cohort change varied by gender. At younger ages, inter-cohort gender differences are more distinct due to a spike in prevalence among boys/men born in or after 1980. Consistent with a gender-specific historical period effect, recent intra-cohort increases among women have narrowed the gender gap. Conclusion: The gender gap in the prevalence of ADHD among adults decreased by 31.1% from 2007 to 2012 due to increased prevalence among adult women of all ages. We discuss these results in relation to diagnostic practice, adult health and well-being, data limitations and needs, and directions for future research.

Emerging Adults in Inpatient Substance Use Treatment: A Prospective Cohort Study of Patient Characteristics and Treatment Outcomes

INTRODUCTION

Compared to older adults, emerging adults treated for substance use disorders (SUDs) are more likely to have unfavorable outcomes. However, few studies have investigated the baseline characteristics and treatment outcomes of emerging adults in inpatient SUD treatment.

AIMS

This study investigated differences in demographic and clinical characteristics and treatment outcomes (relapse or treatment discontinuation) among emerging adult and adult inpatients. Prospective associations between baseline characteristics and unfavorable treatment outcomes were also analyzed across both patient groups.

METHODS

A prospective cohort study was conducted among inpatients (n = 499) at 4 SUD treatment centers in Norway. The sample included emerging adult patients aged 18-25 years (n = 149) and adult patients above 25 years (n = 350). Medical records provided data on sociodemographic variables, substance use characteristics, diagnoses, and treatment completion status. Self-reported measures, including age of onset of substance use, motivation, and mental distress, were completed within 2 weeks of admission to treatment. A telephone interview 3 months after discharge provided information about relapses.

RESULTS

Emerging adults had a more adverse risk profile in terms of demographic characteristics, clinical variables, and treatment outcomes. Multivariable results showed that polysubstance use and an attention deficit hyperactivity disorder (ADHD) diagnosis were the strongest predictors of unfavorable treatment outcomes for emerging adults. For older adults, only baseline mental distress was a significant predictor of unfavorable treatment outcomes.

CONCLUSIONS

Treatment and follow-up initiatives could be better tailored for emerging adults. Identification of treatment needs among emerging adults manifesting polysubstance use and ADHD may reduce the likelihood of unfavorable treatment outcomes in this patient group.

Is ADHD severity in adults associated with the lifetime prevalence of comorbid depressive episodes and anxiety disorders?

Purpose:

The objective of the present study was to examine the association between ADHD severity and the lifetime prevalence of comorbid depressive episodes and anxiety disorders in adults with ADHD.

Subjects/materials and methods:

Analyses were based on data of the Conner's Adult ADHD Rating Scale (CAARS) and a parent study examining the epidemiology of adult ADHD in 17 GP practices in Budapest, Hungary. Subjects between 18 and 60 years were included in the screening phase (n = 3529). Out of 279 positively screened subjects 161 participated in a clinical interview and completed the CAARS to confirm the diagnosis. We applied four diagnostic criteria: “DSM-IV”; “No-onset” (DSM-IV criteria without the specific requirement for onset); “Symptoms-only” (DSM-IV symptom criterion only); and “Reduced symptoms-only” (DSM-IV symptom criterion with a reduced threshold for symptom count). The MINI PLUS 5.0 was used to assess psychiatric comorbidity.

Results:

ADHD severity, as measured by the CAARS ADHD Index, showed a significant positive association with the prevalence of comorbid depressive episodes in all but the “ADHD_No-onset” group (“DSM-IV”: F[1.23] = 8.39, P = 0.0081; “No-onset”: F(1.27) = 0.97, P = 0.3346; “Symptoms-only”: F[1.55] = 30.79, P < 0.0001; “Reduced symptoms-only”: F(1.62) = 26.69, P < 0.0001).

Discussion and conclusion:

Results indicate that ADHD symptom severity increases in association with lifetime comorbidity with depression.

High-Frequency Pornography Use May Not Always Be Problematic

BACKGROUND

Previously, variable-centered analytic approaches showed positive, weak-to-moderate associations between frequency of pornography use (FPU) and problematic pornography use (PPU). However, person-centered studies are sparse in the literature, and these could provide insight into whether there are individuals who use pornography frequently and do not experience problems or whether there are individuals with comparable high-frequency use who differ on reported experiencing of negative consequences.

AIM

The aims of the present study were (i) to identify profiles of pornography use based on FPU and PPU by applying a person-centered analytic approach and (ii) to examine whether the identified profiles could be distinguished based on theoretically relevant demographic and psychological constructs.

METHODS

Latent profile analyses were conducted on 3 nonclinical samples recruited from general websites and a pornography site (study 1: N = 14,006; study 2: N = 483; study 3: N = 672).

RESULTS

Results were consistent across all studies. 3 distinct pornography-use profiles emerged: nonproblematic low-frequency pornography use (68-73% of individuals), nonproblematic high-frequency pornography use (19-29% of individuals), and problematic high-frequency use (3-8% of individuals). Nonproblematic and problematic high-frequency-use groups showed differences in several constructs (ie, hypersexuality, depressive symptoms, boredom susceptibility, self-esteem, uncomfortable feelings regarding pornography, and basic psychological needs).

CLINICAL TRANSLATION

FPU should not be considered as a sufficient or reliable indicator of PPU because the number of people with nonproblematic high-frequency use was 3-6 times higher than that with problematic high-frequency use. These results suggest that individuals with PPU use pornography frequently; however, FPU may not always be problematic.

STRENGTHS & LIMITATIONS

Self-report cross-sectional methods have possible biases that should be considered when interpreting findings (eg, underreporting or overreporting). However, the present research included 3 studies and involved large community samples and visitors of a pornography website. The present study is the first that empirically investigated pornography-use profiles with a wide range of correlates using both severity of PPU and FPU as profile indicators on specific and general samples.

CONCLUSION

The present study is a first step in the differentiated examination of pornography-use profiles, taking into consideration both PPU and FPU, and it provides a foundation for further clinical and large-scale studies. Different psychological mechanisms may underlie the development and maintenance of FPU with or without PPU, suggesting different treatment approaches. Therefore, the present results may guide clinical work when considering reasons for seeking treatment for PPU. Bőthe B, Tóth-Király I, Potenza MN, et al. High-Frequency Pornography Use May Not Always Be Problematic. J Sex Med 2020;17:793-811.

Adult attention-deficit/hyperactivity disorder, risky substance use and substance use disorders: a follow-up study among young men

We investigated whether adult attention-deficit/hyperactivity disorder (ADHD) predicts risky substance use and substance use disorders (SUDs), and its impact on the course of these problematic substance use patterns. Our sample included 4975 Swiss men (mean age 20 ± 1.2 years) who participated in the baseline and 15-month follow-up assessments of the Cohort Study on Substance Use Risk Factors. We examined: (1) the contribution of ADHD, as assessed at baseline, on the risky use of alcohol, nicotine and cannabis, and their corresponding use disorders (AUD, NUD, CUD) at follow-up; and (2) the association between ADHD and the course of outcomes (i.e., absence, initiation, maturing out, persistence) over 15 months. All analyses were adjusted for socio-demographics and co-morbidity. Men with ADHD were more likely to exhibit persistent risky alcohol and nicotine use, and to mature out of risky cannabis use. ADHD at baseline was positively linked to AUD and negatively to CUD at follow-up, but not to NUD. For all SUDs, ADHD had a positive association with use persistence and maturing out. Comparing these two trajectories revealed that early age of alcohol use initiation distinguished between persistence and maturing out of AUD, while the course of NUD and CUD was related to ADHD symptoms and SUD severity at baseline. Already in their early twenties, men with ADHD are especially likely to exhibit persistent problematic substance use patterns. Substance-specific prevention strategies, particularly implemented before early adulthood, may be crucial to reducing the development and persistence of pathological patterns in such individuals.

Maternal ADHD Symptoms and Parenting Stress: The Roles of Parenting Self-Efficacy Beliefs and Neuroticism

OBJECTIVE

ADHD symptoms in adults are consistently related to stress in a variety of domains, although whether the link between ADHD symptoms and stress is direct, or accounted for or moderated by other variables, is little studied. We used a cross-sectional design to examine whether parenting self-efficacy accounts for the relation between maternal ADHD symptoms and parenting stress, and whether levels of maternal neuroticism moderate this relation.

METHOD

A nonclinical sample of mothers of 120, six- to 12-year-old children completed surveys online.

RESULTS

Maternal ADHD symptoms were associated with parenting stress, but this relation was accounted for by parenting self-efficacy beliefs. Neuroticism did not moderate the relations among these variables. Covariate analyses indicated that although parenting self-efficacy beliefs remain a robust predictor of parenting stress, the relation between maternal ADHD symptoms and parenting stress can be better accounted for by other variables.

CONCLUSION

The results highlight the importance of self-efficacy beliefs and demonstrate that ADHD symptoms are not sufficient to understand the experience of parenting.

Distribution of ADHD symptoms, and associated comorbidity, exposure to risk factors and disability: Results from a general population study

The aim of this study was to examine whether ADHD is a dimensional trait in the adult general population. We studied whether an increased number of ADHD symptoms was associated with higher comorbidity, exposure to risk factors (childhood abuse and parental psychopathology), and disability. We ascertained whether even low numbers of ADHD symptoms were associated with an increased burden of disease. Data were used from the second wave of the Netherlands Mental Health Survey and Incidence Study-2 (NEMESIS-2, N = 5303). NEMESIS-2 is a nationally representative face-to-face survey on mental health of the Dutch general population. ADHD symptoms, mental comorbidity, and disability were assessed using the Adult ADHD Self-Report Scale Screener, the Composite International Diagnostic Interview version 3.0, and the Medical Outcomes Study Short Form Health Survey, respectively. Dose-response relationships were found between the number of ADHD symptoms and Axis I and II mental disorders; exposure to risk factors; and mental and physical disability. Our study supports the notion that ADHD is a dimensional trait in the adult general population. Even low numbers of symptoms were associated with an increased burden of disease, and therefore these should be identified and treated.

Is dopamine transporter-mediated dopaminergic signaling in the retina a noninvasive biomarker for attention-deficit/ hyperactivity disorder? A study in a novel dopamine transporter variant Val559 transgenic mouse model

Background

Dopamine (DA) is a critical neuromodulator in the retina. Disruption of retinal DA synthesis and signaling significantly attenuates light-adapted, electroretinogram (ERG) responses, as well as contrast sensitivity and acuity. As these measures can be detected noninvasively, they may provide opportunities to detect disease processes linked to perturbed DA signaling. Recently, we identified a rare, functional DA transporter (DAT, SLC6A3) coding substitution, Ala559Val, in subjects with attention-deficit/hyperactivity disorder (ADHD), demonstrating that DAT Val559 imparts anomalous DA efflux (ADE) with attendant physiological, pharmacological, and behavioral phenotypes. To understand the broader impact of ADE on ADHD, noninvasive measures sensitive to DAT reversal are needed.

Methods

Here, we explored this question through ERG-based analysis of retinal light responses, as well as HPLC measurements of retinal DA in DAT Val559 mice.

Results

Male mice homozygous (HOM) for the DAT Val559 variant demonstrated increased, light-adapted ERG b-wave amplitudes compared to wild type (WT) and heterozygous (HET) mice, whereas dark-adapted responses were indistinguishable across genotypes. The elevated amplitude of the photopic light responses in HOM mice could be mimicked in WT mice by applying D₁ and D₄ DA receptor agonists and suppressed in HOM mice by introducing D₄ antagonist, supporting elevated retinal DA signaling arising from ADE. Following the challenge with amphetamine, WT exhibited an increase in light-adapted response amplitudes, while HOM did not. Total retinal DA content was similar across genotypes. Interestingly, female DAT Val559 HOM animals revealed no significant difference in photopic ERG responses when compared with WT and HET littermates.

Conclusions

These data reveal that noninvasive, in vivo evaluation of retinal responses to light can reveal physiological signatures of ADE, suggesting a possible approach to the segregation of neurobehavioral disorders based on the DAT-dependent control of DA signaling.

Parental psychopathology and offspring attention-deficit/hyperactivity disorder in a nationwide sample

OBJECTIVE

To study the associations between a wide range of parental psychiatric disorders and offspring attention-deficit/hyperactivity disorder (ADHD).

METHOD

This study is based on a nested case-control design. The association between parental registered psychiatric diagnoses and offspring ADHD was examined adjusting for socioeconomic and prenatal factors. Data was linked from Finnish nationwide registers. The cases (n = 10,409) were all the children born between years 1991 and 2005 in Finland and diagnosed with ADHD by the end of 2011. Four controls without ADHD (n = 39,124) were matched for every case by sex, age and place of birth. Main outcomes were adjusted odds ratio (aOR) for parental diagnosis of cases vs controls. Analyses were further stratified by sex. Disorders diagnosed before and after birth were analyzed separately.

RESULTS

The odds ratio for ADHD increased when only mother (aOR 2.2, 95% CI 2.0-2.3), only father (aOR 1.7, 95% CI 1.6-1.8) and both parents (aOR 3.6, 95% CI 3.3-4.0) were diagnosed. Maternal diagnosis showed stronger association than paternal. The weight of association between several parental disorders and offspring ADHD were similar. Maternal psychopathology overall showed stronger associations with girls than boys with ADHD. The diagnoses registered after birth did not show stronger association than the diagnoses registered before.

CONCLUSIONS

Maternal psychopathology showing stronger association than paternal implies that environmental factors or their interaction with genetic factors partly mediates the risk of parental psychopathology. Similar associations between several maternal psychiatric disorders and offspring ADHD points towards the need for investigating some common mother-related risk factors.

Exploring DSM-5 ADHD criteria beyond young adulthood: phenomenology, psychometric properties and prevalence in a large three-decade birth cohort

BACKGROUND

There are still uncertainties on the psychometric validity of the DSM-5 attention deficit hyperactivity disorder (ADHD) criteria for its use in the adult population. We aim to describe the adult ADHD phenotype, to test the psychometric properties of the DSM-5 ADHD criteria, and to calculate the resulting prevalence in a population-based sample in their thirties.

METHOD

A cross-sectional evaluation using the DSM-5 ADHD criteria was carried out in 3574 individuals from the 1982 Pelotas Birth Cohort. Through receiver operator curve, latent and regression analyses, we obtained parameters on construct and discriminant validity. Still, prevalence rates were calculated for different sets of criteria.

RESULTS

The latent analysis suggested that the adult ADHD phenotype is constituted mainly by inattentive symptoms. Also, inattention symptoms were the symptoms most associated with impairment. The best cut-off for diagnosis was four symptoms, but sensitivity and specificity for this cut-off was low. ADHD prevalence rates were 2.1% for DSM-5 ADHD criteria and 5.8% for ADHD disregarding age-of-onset criterion.

CONCLUSIONS

The bi-dimensional ADHD structure proposed by the DSM demonstrated both construct and discriminant validity problems when used in the adult population, since inattention is a much more relevant feature in the adult phenotype. The use of the DSM-5 criteria results in a higher prevalence of ADHD when compared to those obtained by DSM-IV, and prevalence would increase almost threefold when considering current ADHD syndrome. These findings suggest a need for further refinement of the criteria for its use in the adult population.

The descriptive epidemiology of DSM-IV Adult ADHD in the World Health Organization World Mental Health Surveys

We previously reported on the cross-national epidemiology of ADHD from the first 10 countries in the WHO World Mental Health (WMH) Surveys. The current report expands those previous findings to the 20 nationally or regionally representative WMH surveys that have now collected data on adult ADHD. The Composite International Diagnostic Interview (CIDI) was administered to 26,744 respondents in these surveys in high-, upper-middle-, and low-/lower-middle-income countries (68.5% mean response rate). Current DSM-IV/CIDI adult ADHD prevalence averaged 2.8% across surveys and was higher in high (3.6%)- and upper-middle (3.0%)- than low-/lower-middle (1.4%)-income countries. Conditional prevalence of current ADHD averaged 57.0% among childhood cases and 41.1% among childhood subthreshold cases. Adult ADHD was significantly related to being male, previously married, and low education. Adult ADHD was highly comorbid with DSM-IV/CIDI anxiety, mood, behavior, and substance disorders and significantly associated with role impairments (days out of role, impaired cognition, and social interactions) when controlling for comorbidities. Treatment seeking was low in all countries and targeted largely to comorbid conditions rather than to ADHD. These results show that adult ADHD is prevalent, seriously impairing, and highly comorbid but vastly under-recognized and undertreated across countries and cultures.

Burden of illness and health care resource utilization in adult psychiatric outpatients with attention-deficit/hyperactivity disorder in Europe

OBJECTIVE

To assess the burden of illness and health care resource utilization of adult nonpsychotic psychiatric outpatients with attention-deficit/hyperactivity disorder (ADHD) in Europe.

METHODS

This was a multicountry, cross-sectional, observational study where unselected routine patients from clinical psychiatric outpatient settings were screened and assessed for ADHD. Patients were evaluated using the Clinical Global Impressions of Severity (CGI-S) scale, the Sheehan Disability Scale (SDS), and the EuroQol-5 Dimensions questionnaire. Data on comorbidities, functional impairment, and health care resource utilization were captured.

RESULTS

The study enrolled 2284 patients, of whom 1986 completed the study. The prevalence of ADHD was 17.4%, of whom 46.0% had a previous ADHD diagnosis. Patients with ADHD had a high clinical burden with psychiatric comorbidities, especially depression (43.0%) and anxiety disorders (36.4%). Substance abuse (9.2% vs. 3.4%) and alcohol abuse (10.3% vs. 5.2%) were more common in the ADHD cohort vs. the non-ADHD cohort. Only 11.5% of the patients with ADHD had no other psychiatric disorder. Various measures indicated a significantly poorer level of functioning for patients with ADHD than without ADHD, as indicated by higher scores for CGI-S (3.8 vs. 3.3) and SDS (18.9 vs. 11.6) and higher percentages of debt (35.5% vs. 24.3%) and criminality (13.8% vs. 6.1%). Lastly, the health care resource utilization was considerable and similar between adult psychiatric outpatients diagnosed and not diagnosed with ADHD.

CONCLUSIONS

Although care was taken when choosing the sites for this study, to make it representative of the general outpatient adult psychiatric population, caution should be advised in generalizing the findings of our study to the general ADHD or psychiatric outpatient population. This was an observational study, thus no inference on causality can be drawn. Having ADHD imposes a considerable health and social burden on patient and health care resource utilization comparable to other chronic psychiatric disorders.

The intraindividual impact of ADHD on the transition of adulthood to old age

The aim of the study was to explore whether the individual burden of ADHD is the same in the elderly as in younger ages even though the symptomatological impact of ADHD seems to remain stable over the lifespan. To assess ADHD symptoms and ADHD-associated problems in daily life, standardised questionnaires were conducted. To assess the subjectively experienced course of disease over the lifespan, all participants were interviewed regarding symptoms of ADHD in childhood as well as before and after the fiftieth year of life. In the sample of 296 respondents with a mean age of 69.55 years, 11 fulfilled the criteria of adult ADHD. Retrospectively, the ADHD subjects reported negative impacts due to ADHD-associated behaviour over the life span. These impairments remained stable over time with 18 % of subjects reporting impairments in family life, 46 % in social relationships, 18 % in dealing with money, and 36 % in organisation of daily life in the presence. Thus, the ADHD subjects reported problems with stability over time caused by low self-confidence, being quick-tempered, and due to defiantness. Although this is pilot study, our results reflect the burden of ADHD not only in young and middle adulthood, but also in seniority. The findings indicate the lifelong impact of ADHD as the explored seniors with ADHD reported the negative impact of ADHD remaining stable over the lifespan.

Adult Attention Deficit Hyperactivity Disorder Symptoms, Perceived Stress, and Well-Being: The Role of Early Maladaptive Schemata

Attention deficit hyperactivity disorder (ADHD) is one of the most prevalent chronic neuropsychiatric disorders, severely affecting the emotional well-being of children as well as of adults. It has been suggested that individuals who experience symptoms of ADHD develop maladaptive schemata of failure, impaired self-discipline, social isolation, and shame. These schemata may then contribute to impaired emotional well-being by increasing unhelpful responses to stressful life events. However, to date, no empirical research has tested this theoretical proposition. In a sample of 204 nonclinical adults, we conducted a serial multiple mediator analysis, which supported the proposed model. More severe ADHD symptoms were associated with higher levels of perceived stress both directly and indirectly through stronger maladaptive schemata, which, in turn, were related to lower levels of emotional well-being. Results suggest that identifying and modifying maladaptive schemata may be an important addition to psychotherapy for adult ADHD patients.

A network meta-analysis of atomoxetine and osmotic release oral system methylphenidate in the treatment of attention-deficit/hyperactivity disorder in adult patients

The lack of head-to-head clinical studies powered to compare atomoxetine and osmotic release oral system (OROS) methylphenidate necessitates treatment comparison by methods that include indirect evidence such as network meta-analysis (NMA). A NMA assessing the relative treatment effects of atomoxetine and OROS methylphenidate in adults with attention-deficit/hyperactivity disorder (ADHD) was conducted. Studies were identified by systematic literature review. Analyses summarised improvements in efficacy, measured by ADHD-specific scales, using Cohen'sdto calculate the standardised mean difference (SMD), and all cause discontinuations. Results showed effect sizes (SMD, 95% credible interval (CrI)) relative to placebo that did not differ significantly between atomoxetine (0.46, 0.36-0.56) and OROS methylphenidate (0.51, 0.40-0.63) in clinical studies of up to 12 weeks' duration (SMD, 95% CrI for atomoxetine versus OROS methylphenidate: -0.05, -0.18-0.08). Patients treated with these medications responded better than those given placebo across all analyses. There was also no significant difference in discontinuation rates between atomoxetine and OROS methylphenidate (odds ratio, 95% CrI: 0.85, 0.53-1.35). Between-study heterogeneity was low overall. Results of this NMA suggest that the efficacy of atomoxetine and OROS methylphenidate in adults does not differ significantly. Clinical guidelines may require amendment to reflect these recent data.

Gender differences in adults with attention-deficit/hyperactivity disorder: A narrative review

Certain characteristics of attention-deficit/hyperactivity disorder (ADHD) in children have long been known to differ by gender. What has not been as widely studied is whether gender is similarly associated with ADHD differences in adults. In this review, the relation between gender and adult ADHD prevalence, persistence, impairment, comorbidity, cognitive functioning, and treatment response was examined across 73 studies. Although gender was related to several characteristics and correlates of adult ADHD, it appeared that many of these gender differences may be at least be partially attributed to methodological artifacts or social and cultural influences, rather than fundamental differences in the expression of ADHD in men and women. We highlight how understanding the nature of the relation between gender and ADHD across the lifespan is complicated by a number of methodological difficulties, and offer recommendations for how emerging research and clinical practice can better incorporate gender into the conceptualization of ADHD in adulthood.

Safety and tolerability of atomoxetine in treatment of attention deficit hyperactivity disorder in adult patients: an integrated analysis of 15 clinical trials

The safety profile of atomoxetine in the treatment of attention deficit hyperactivity disorder has been studied in many clinical trials. We performed an integrated safety analysis of 15 clinical trials in adults with attention deficit hyperactivity disorder. The analysis pooled patient data into three groups: acute placebo-controlled trials; long-term placebo-controlled trials; all trials. In total, 4829 adults (18-77 years, median: 36 years) were exposed to atomoxetine. Statistically significantly more atomoxetine-treated than placebo-treated patients experienced treatment-emergent adverse events (81.3% vs. 68.3% acute; 90.6% vs. 76.8% long term) and discontinued due to adverse events (8.9% vs. 4.0% acute; 17.9% vs. 6.3% long term). No statistically significant differences were observed in the proportion of patients experiencing serious adverse events. No previously unknown adverse events were identified. The most common adverse events included nausea, dry mouth, decreased appetite, insomnia and erectile dysfunction. Mean increases in heart rate (+5.2 beats per min) and blood pressure (systolic +2 mmHg, diastolic +1.9 mmHg) were modest. The proportion of patients experiencing clinically significant increases in blood pressure and heart rate at any time was statistically significantly higher with atomoxetine (systolic blood pressure 13-17%, diastolic blood pressure 37-40%, heart rate 42-43%) compared to placebo (systolic blood pressure 8-13%, diastolic blood pressure 29-34%, heart rate 21-26%). There was no increased risk of suicidal ideation or behaviour. Our findings confirm atomoxetine's known safety profile. From a safety perspective, atomoxetine is a useful treatment option for adults with attention deficit hyperactivity disorder.

Differential diagnosis, comorbidity, and treatment of attention-deficit/hyperactivity disorder in relation to bipolar disorder or borderline personality disorder in adults

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) in adults can resemble, and often co-occurs with, bipolar disorder (BD) and borderline personality disorder (BPD). This can lead to mistaken diagnoses and ineffective treatment, resulting in potentially serious adverse consequences. All three conditions can substantially impair well-being and functioning, while BD and BPD are associated with suicidality.

OBJECTIVES

To update clinicians on the overlap and differences in the symptomatology of ADHD versus BD and BPD in adults; differential diagnosis of ADHD from BD and BPD in adults; and diagnosis and treatment of adults with comorbid ADHD-BD or ADHD-BPD.

METHODS

We searched four databases, referred to the new Diagnostic and Statistical Manual of Mental Disorders, 5th edition, used other relevant literature, and referred to our own clinical experience.

RESULTS

ADHD coexists in ∼20% of adults with BD or BPD. BD is episodic, with periods of normal mood although not necessarily function. In patients with comorbid ADHD-BD, ADHD symptoms are apparent between BD episodes. BPD and ADHD are associated with chronic trait-like symptoms and impairments. Overlapping symptoms of BPD and ADHD include impulsivity and emotional dysregulation. Symptoms of BPD but not ADHD include frantically avoiding real/imagined abandonment, suicidal behavior, self-harm, chronic feelings of emptiness, and stress-related paranoia/severe dissociation. Consensus expert opinion recommends that BD episodes should be treated first in patients with comorbid ADHD, and these patients may need treatment in stages (e.g. mood stabilizer[s], then a stimulant/atomoxetine). Data is scarce and mixed about whether stimulants or atomoxetine exacerbate mania in comorbid ADHD-BD. BPD is primarily treated with psychotherapy. Principles of dialectical behavioral treatment for BPD may successfully treat ADHD in adults, as an adjunct to medication. No fully evidence-based pharmacotherapy exists for core BPD symptoms, although some medications may be effective for individual symptom domains, e.g. impulsivity (shared by ADHD and BPD). In our experience, treatment of ADHD should be considered when treating comorbid personality disorders.

CONCLUSIONS

It is important to accurately diagnose ADHD, BD, and BPD to ensure correct targeting of treatments and improvements in patient outcomes. However, there is a shortage of data about treatment of adults with ADHD and comorbid BD or BPD.

Underdiagnosis of attention-deficit/hyperactivity disorder in adult patients: a review of the literature

OBJECTIVE

To raise awareness of attention-deficit/hyperactivity disorder (ADHD) as an underdiagnosed, undertreated, often comorbid, and debilitating condition in adults.

DATA SOURCES

PubMed was searched using combinations of keywords, including ADHD, adult, diagnosis, identify, prevalence, and comorbid, to find articles published between 1976 and 2013.

STUDY SELECTION

In total, 99 articles were selected for inclusion on the basis of their relevance to the objective and importance to and representation of ADHD research, including international guidelines for adults with ADHD.

RESULTS

In a large proportion of children with ADHD, symptoms persist into adulthood. However, although adults with ADHD often experience chaotic lifestyles, with impaired educational and vocational achievement and higher risks of substance abuse and imprisonment, many remain undiagnosed and/or untreated. ADHD is usually accompanied by other psychiatric comorbidities (such as major depressive disorder, anxiety disorder, and alcohol abuse). Indeed, adults with ADHD are more likely to present to a psychiatric clinic for treatment of their comorbid disorders than for ADHD, and their ADHD symptoms are often mistaken for those of their comorbidities. Untreated ADHD in adults with psychiatric comorbidities leads to poor clinical and functional outcomes for the patient even if comorbidities are treated. Effective treatment of adults' ADHD improves symptoms, emotional lability, and patient functioning, often leading to favorable outcomes (eg, safer driving, reduced criminality). A few medications have now been approved for use in adults with ADHD, while a multimodal approach involving psychotherapy has also shown promising results. Conclusions General psychiatrists should familiarize themselves with the symptoms of ADHD in adults in order to diagnose and manage ADHD and comorbidities appropriately in these patients.

Prevalence of and associated factors for adult attention deficit hyperactivity disorder in young Swiss men

OBJECTIVE

The present study aimed to measure the prevalence of adult attention deficit hyperactivity disorder (ADHD) in a large, representative sample of young Swiss men and to assess factors associated with this disorder.

METHODS

Our sample consisted of 5656 Swiss men (mean age 20 years) who participated in the Cohort Study on Substance Use Risk Factors (C-SURF). ADHD was assessed with the World Health Organization (WHO) adult ADHD Self Report Screener (ASRS). Logistic regression analyses were conducted to assess the association between ADHD and several socio-demographic, clinical and familial factors.

RESULTS

The prevalence of ADHD was 4.0%, being higher in older and French-speaking conscripts. A higher prevalence also was identified among men whose mothers had completed primary or high school/university and those with a family history of alcohol or psychiatric problems. Additionally, adults with ADHD demonstrated impairment in their professional life, as well as considerable mental health impairment.

CONCLUSION

Our results demonstrate that ADHD is common among young Swiss men. The impairments in function and mental health we observed highlight the need for further support and interventions to reduce burden in affected individuals. Interventions that incorporate the whole family also seem crucial.

Functional impairment in adults positively screened for attention-deficit hyperactivity disorder: the role of symptom presentation and executive functioning

BACKGROUND

While the number of symptoms of attention-deficit hyperactivity disorder (ADHD) decreases with age, a high proportion of adults with ADHD symptoms suffer from persistent functional impairment (Fi) linked to these symptoms. Our objective was to investigate the specific roles of two potentially important predictors of this Fi: the clinical symptom presentation and the deficit in executive functions (EFs).

METHODS

A total of 158 subjects from a community sample positively screened for ADHD were classified into two groups: those with and without Fi. Following a detailed diagnostic process, participants were administered a self-rating scale for ADHD symptoms as well as a neuropsychological test battery containing tests of EF and attention relevant as potential cognitive endophenotypes for ADHD.

RESULTS

The overall number as well as the number of inattentive, hyperactive and impulsive symptoms, confirmed both by examiner and self-report, were significantly higher among Fi subjects. The highest odds ratio for Fi was associated with impulsive symptoms. Additionally, self-reported complaints of problems with self-concept were significantly higher among Fi subjects. No significant relationship between Fi and neuropsychological measures of EF and attention was detected.

CONCLUSIONS

This study revealed that the number of symptoms, in particular that of impulsivity, had a significant impact on Fi in adults with symptoms of ADHD. Furthermore, our results underline the importance of assessing complaints and behaviors related to self-concept, which are not included in DSM-IV diagnostic criteria of ADHD but nonetheless may be associated with functional outcome of the disorder.

Attention deficit hyperactivity disorder in the European adult population: prevalence, disease awareness, and treatment guidelines

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is a chronic neurobiological disorder with childhood onset and persistence into adolescence and adulthood.

METHODS

Our literature review reports scientific publications and guidelines on the treatment of adult ADHD, with a particular focus on European countries, identified by literature searches in Medline and Embase. The final literature search was performed in July 2012, incorporating literature from 1974 to 2012. The primary research parameters were 'Europe' (including single European countries), 'ADHD', 'attention deficit disorder', 'attention deficit', 'attention disorder', and 'hyperactivity'. Secondary search parameters were 'comorbid', 'epidemiology' or 'prevalence', 'disease management', 'drug therapy', or 'therapy'. The main searches were also limited to adults and English language publications. The papers identified by this literature review were selected for inclusion by consensus of the authors based on clinical relevance.

RESULTS

Appropriate resources for the diagnosis and treatment of adult ADHD in Europe are scarce, and many cases go untreated, particularly because of the frequent presence of psychiatric comorbidities. Apart from atomoxetine, and an extended-release form of methylphenidate in Germany, no other medications have been approved for starting treatment in adult ADHD patients in the European Union. However, a variety of stimulant and non-stimulant medications are used off-label, and a number of studies have confirmed that these medications are well tolerated and effective in adult patients with ADHD.

CONCLUSIONS

Our results emphasize the need for broader access to effective treatments for adult ADHD patients in Europe.

Standardized diagnostic interviews, criteria, and algorithms for mental disorders: garbage in, garbage out

There is a general consensus that diagnoses for mental disorders should be based on criteria and algorithms as given in ICD or DSM. Standardized clinical interviews are recommended as diagnostic methods. In ICD and DSM, much emphasis is put on algorithms, while the underlying criteria get much less attention. The question is how valid are the criteria that are collected by structured diagnostic interviews. 209 patients from a cardiology inpatient unit were interviewed with the Mini International Neuropsychiatric Interview (MINI). 32 (15.3%) were diagnosed as suffering from a major depressive episode or dysthymia. Additionally, a thorough clinical examination was done by a psychiatric expert in 15 patients. The standardized diagnosis of present major depression was reaffirmed in one. In total, four patients were suffering from some kind of depressive disorder presently or life time. Two patients were suffering from anxiety disorders, two from adjustment disorders, and four from different types of organic brain disorders. Most important, there are 3 out of 15 who are not mentally ill. Our observations show that standardized diagnostic interviews cannot be used to make specific differential diagnoses, but rather catch unspecific syndromes. This is partly due to the fact that the wording, definition, and understanding of the underlying criteria is rather vague. This is an even greater problem if there is any somatic comorbidity. In the revision of ICD and DSM, a glossary of psychopathological terms and guidelines for the training of clinicians should be included.

State of psychiatry in Hungary

Hungary has a tradition both in biological psychiatry and psychotherapy, and for decades developed together with neurology. From the mid 1980s the speed of development of psychiatry started lagging behind expected standards. Psychiatric care, research and teaching were hit hard in 2007 by unprecedented closures of facilities and budget reductions. Although suicide rates have decreased since the mid 1980s, the country has still the second highest rate in the European Union. The high prevalence of alcohol use and the rapidly increasing prevalence of illicit drug use contribute to comorbidity and related behavioural issues, including the increased frequency of severe violent events committed by people with psychiatric disorders, which have not been properly addressed. The country expects the first major restructuring of its healthcare starting in 2012 since the major political changes of 1989/1990. The profession, patients and their caregivers should use this opportunity to modernize psychiatry in Hungary.

A population-based study of attention deficit/hyperactivity disorder symptoms and associated impairment in middle-aged adults

Attention deficit/hyperactivity disorder (ADHD) is the most prevalent childhood psychiatric condition. It frequently persists into adulthood and can have serious health and other adverse consequences. The majority of previous adult ADHD studies have focused on young adults so that relatively little is known about ADHD symptoms and their effects in mid and late life. In addition, effects of subclinical levels of attention deficit and hyperactivity have not been studied in detail. In this study we investigated ADHD symptoms and related impairment in a large population-based sample of middle-aged Australian adults (n = 2091; 47% male). Applying the WHO adult ADHD Self Report Screener (ASRS) we observed that 6.2% of participants had scores that were previously associated with ADHD diagnosis. No significant gender difference in the distribution of ASRS scores was observed. Multiple regression analyses indicated strong positive correlations between symptoms of ADHD and depression/anxiety and significant negative associations (p<0.01) with employment, financial stress, relationship quality, health and well-being measures in this age group. Importantly, associations were highly significant even when few ADHD symptoms were reported. Compared to the hyperactivity component, the inattention trait was particularly strongly associated and remained significant after controlling for depression/anxiety symptoms. Our study confirms previous findings and significantly adds to existing literature especially for an age-group that has not been well-studied. Our results suggest that ADHD symptoms continue to be associated with ill-health and functional impairment in mid-life and are, therefore, likely to be a major, previously unrecognized source of late-life morbidity with associated social and economic costs. Thus, there is a compelling need for better understanding and development of age-appropriate approaches to the diagnosis and treatment of ADHD in mid- to late-life.

The estimated prevalence and correlates of adult ADHD in a German community sample

Little research on the prevalence and correlates of adult ADHD has been conducted outside the United States. The aim of the present study was to estimate the prevalence and correlates of adult ADHD in a large representative sample of the German population aged 18-64 years (n = 1,655). Two self-rating screening instruments to assess childhood and adult ADHD symptomatology were used to estimate the prevalence of ADHD. A 4-item screening tool was used to assess probable cases of current depression and anxiety (Patient Health Questionnaire). The estimated crude prevalence rate of current ADHD was 4.7%. Adult ADHD was significantly associated with lower age, low educational level, unemployment, marital status (never married and divorced), and rural residency. No association was found with gender. Adult ADHD was strongly associated with positive screening results for depression and anxiety. ADHD is a common disorder of adulthood, is associated with significant social impairment and psychiatric co-morbidity, and should receive further research attention.

Pharmacologic treatment of attention-deficit/hyperactivity disorder in children: incidence, prevalence, and treatment patterns in the Netherlands

BACKGROUND

The prevalence of attention-deficit/hyperactivity disorder (ADHD) and the associated use of stimulant medications may have increased in the Netherlands in recent years, but there is a lack of data to confirm this trend. This retrospective analysis examined the incidence, prevalence, and treatment pattern of ADHD among children from a large sample representation of the general population of the Netherlands and represents the first such analysis in a large cohort of European children.

OBJECTIVE

The aim of this study was to estimate the incidence and prevalence of children receiving initial pharmacotherapy for ADHD between 2000 and 2007 in the Netherlands and to describe treatment patterns (including persistence and adherence to ADHD medications) in this pediatric population.

METHODS

Prescription and hospitalization data from the PHARMO medical record linkage system database in the Netherlands (2003 to 2006) were analyzed for patients with newly prescribed ADHD medication who were aged 6 to 17 years and received follow-up for at least 12 months after treatment initiation with methylphenidate, dexamphetamine, atomoxetine, or combination therapy. The yearly incidence and prevalence of children receiving ADHD pharmacotherapy were estimated for the period 2000 to 2007. Demographic characteristics and baseline medication data at treatment initiation were collected along with data on hospitalizations and psychotropic treatments in the year before initiation of ADHD treatment.

RESULTS

Of the 4909 patients in the study cohort, 82% were male and 46% were between 6 and 9 years of age. The yearly incidence of children receiving ADHD medication--extrapolated from the PHARMO database to the Netherlands population--increased from 30 per 10,000 in the year 2000 to 75 per 10,000 in the year 2007. Prevalence rates showed a similar trend, increasing from 110 per 10,000 in 2000 to 210 per 10,000 in 2007. Prevalence and incidence rates both were consistently higher among boys than girls, although the greatest increases over time were observed in female patients. Analysis of treatment patterns revealed that most children (98%) initiated treatment with methylphenidate. Of those, 89% received an immediate-release formulation, although increased use of long-acting amphetamine and atomoxetine was apparent over the study period. Persistence and adherence rates varied according to the medications used and the prescribing physician. Antipsychotic agents and melatonin were the most commonly used therapeutics in the year before ADHD treatment initiation (6% and 4% of patients, respectively).

CONCLUSIONS

The incidence and prevalence of children treated for ADHD increased from 2000 to 2007. Most children (98%) initiated treatment with immediate-release methylphenidate.

Attention-deficit/hyperactivity disorder in childhood is associated with cognitive test profiles in the geriatric population but not with mild cognitive impairment or Alzheimer's disease

The frequency of ADHD in the aging population and its relationship to late-life cognitive decline has not been studied previously. To address this gap in our understanding, the Wender-Utah ADHD Rating scale (WURS) was administered to 310 geriatric subjects with cognitive status ranging from normal cognition to mild cognitive impairment to overt dementia. The frequency of WURS-positive ADHD in this sample was 4.4%. WURS scores were not related to cognitive diagnoses, but did show nonlinear associations with tasks requiring sustained attention. The frequency of ADHD appears stable across generations and does not appear to be associated with MCI or dementia diagnoses. The association of attentional processing deficits and WURS scores in geriatric subjects could suggest that such traits remain stable throughout life. Caution should be considered when interpreting cognitive test profiles in the aging population that exhibit signs and symptoms of ADHD, as attentional deficits may not necessarily imply the existence of an underlying neurodegenerative disease state.

Epidemiology of adult attention deficit hyperactivity disorder (ADHD) - first hungarian data

Introduction

Although ADHD in childhood is a well known and treated condition in Hungary, until recently there was no epidemiologic data about the prevalence of ADHD among adults.

Objective

Estimation of the prevalence of adult ADHD in Hungary.

Methods

In this study1, 3529 subjects (18 to 60 years) were screened with the Adult Self-Report Scale2 6-item version. Out of 279 positively screened subjects, 161 participated in a detailed semi-structured clinical interview.

Results

ADHD was associated with younger age and male gender [χ2=14.46; p=0.0007], however there was no significant interaction between the effect of gender and age [Estimate: –0.031, SE: 0.043, χ2=0.5124; p=0.4741]1. According to the estimates corrected for the ‘not-interviewed’ subsample and after adjusting for specificity and sensitivity data of the screener, the prevalence of ADHD was 2.3% in males, 0.91% in females; 2.02% in the ≤40 years group and 0.70% in the > 40 years group1. In our sample, 82.61% of male, and 78.94% of female ADHD subjects had at least 1 comorbid psychiatric disorder.

Conclusions

The estimated prevalence of ADHD among adults is in line with data reported in the literature.

Adult attention deficit hyperactivity disorder is associated with migraine headaches

Attention deficit hyperactivity disorder (ADHD) is now recognized as a common disorder both in child and adult psychiatry. Adult patients with a diagnosis of ADHD (n = 572) and community controls (n = 675) responded to auto-questionnaires rating past and present symptoms of ADHD, co-morbid conditions, including migraine, treatment history and work status. The prevalence of migraine was significantly higher in the patient group compared to the controls (28.3% vs. 19.2%, P < 0.001, OR = 1.67, CI 1.28-2.17). The difference from controls was particularly marked for men (22.5% vs. 10.7%, P < 0.001, OR = 2.43, CI 1.51-3.90) but was also significant for women (34.4% vs. 24.9%, P = 0.008, OR = 1.58, CI 1.13-2.21). In both patients and controls, migraine was associated with symptoms of mood and anxiety disorders. These findings point to a co-morbidity of migraine with ADHD, and it is possible that these patients represent a clinical and biological subgroup of adult patients with ADHD.