Depression in Adults with Attention-Deficit/Hyperactivity Disorder (ADHD): The Mediating Role of Cognitive-Behavioral Factors

One-year follow-up of the effectiveness and mediators of cognitive behavioural therapy among adults with attention-deficit/hyperactivity disorder: secondary outcomes of a randomised controlled trial

BACKGROUND

The long-term effectiveness of cognitive behavioural therapy (CBT) in medicated attention-deficit/hyperactivity disorder (ADHD) adults with residual symptoms needs to be verified across multiple dimensions, especially with respect to maladaptive cognitions and psychological quality of life (QoL). An exploration of the mechanisms underlying the additive benefits of CBT on QoL in clinical samples may be helpful for a better understanding of the CBT conceptual model and how CBT works in medicated ADHD.

METHODS

We conducted a secondary analysis of a randomised controlled trial including 98 medicated ADHD adults with residual symptoms who were randomly allocated to the CBT combined with medication (CBT + M) group or the medication (M)-only group. Outcomes included ADHD-core symptoms (ADHD Rating Scale), depression symptoms (Self-rating Depression Scale), maladaptive cognitions (Automatic Thoughts Questionnaire and Dysfunctional Attitude Scale), and psychological QoL (World Health Organization Quality of Life-Brief Version-psychological domain). Mixed linear models (MLMs) were used to analyse the long-term effectiveness at one-year follow-up, and structural equation modeling (SEM) was performed to explore the potential mechanisms of CBT on psychological QoL.

RESULTS

ADHD patients in the CBT + M group outperformed the M-only group in reduction of ADHD core symptoms (d = 0.491), depression symptoms (d = 0.570), a trend of reduction of maladaptive cognitions (d = 0.387 and 0.395, respectively), and improvement of psychological QoL (d = - 0.433). The changes in above dimensions correlated with each other (r = 0.201 ~ 0.636). The influence of CBT on QoL was mediated through the following four pathways: 1) changes in ADHD core symptoms; 2) changes in depressive symptoms; 3) changes in depressive symptoms and then maladaptive cognitions; and 4) changes firstly in depressive symptoms, maladaptive cognitions, and then ADHD core symptoms.

CONCLUSIONS

The long-term effectiveness of CBT in medicated ADHD adults with residual symptoms was further confirmed. The CBT conceptual model was verified in clinical samples, which would be helpful for a deeper understanding of how CBT works for a better psychological QoL outcome.

TRIAL REGISTRATION

ChiCTR1900021705 (2019-03-05).

Exploring the efficacy of dialectical behaviour therapy and methylphenidate on emotional comorbid symptoms in adults with attention Deficit/Hyperactivity disorder: Results of the COMPAS multicentre randomised controlled trial

This study evaluated the efficacy of dialectical behaviour group therapy (GPT) vs. individual clinical management (CM) and methylphenidate (MPH) vs. placebo (PLB) on emotional symptoms in adults with ADHD. This longitudinal multicentre RCT compared four groups (GPT+MPH, GPT+PLB, CM+MPH, and CM+PLB) over five assessment periods, from baseline to week 130. Emotional symptomatology was assessed using SCL-90-R subscales. Of the 433 randomised participants, 371 remained for final analysis. At week 13, the GPT+MPH group showed smaller reductions in anxiety symptoms than the CM groups, but the differences disappeared at subsequent assessments. Improvements in emotional symptom were significantly predicted by reductions in core ADHD symptoms in all groups except the GPT+MPH group. The unexpected lack of between-group differences may be explained by a "floor effect", different intervention settings (group vs. individual), and psychotherapy type. Multiple regression analyses suggest a more specific effect of combined interventions (GPT+MPH). Implications for clinical practice are discussed. Clinical trial registration: ISRCTN54096201 (Current Controlled Trials).

A Digital Mental Health Support Program for Depression and Anxiety in Populations With Attention-Deficit/Hyperactivity Disorder: Feasibility and Usability Study

BACKGROUND

A total of 1 in 2 adults with attention-deficit/hyperactivity disorder (ADHD) struggles with major depressive or anxiety disorders. The co-occurrence of these disorders adds to the complexity of finding utility in as well as adherence to a treatment option. Digital therapeutic solutions may present a promising alternative treatment option that could mitigate these challenges and alleviate symptoms.

OBJECTIVE

This study aims to investigate (1) the feasibility and acceptance of a digital mental health intervention, (2) participants' engagement and retention levels, and (3) the potential efficacy with respect to anxiety and depression symptoms in a population with ADHD. Our main hypothesis was that a digital, data-driven, and personalized intervention for adults with coexisting ADHD and depressive or anxiety symptoms would show high engagement and adherence, which would be accompanied by a decrease in depressive and anxiety symptoms along with an increase in quality of life and life satisfaction levels.

METHODS

This real-world data, single-arm study included 30 adult participants with ADHD symptomatology and coexisting depressive or anxiety symptoms who joined a 16-week digital, data-driven mental health support program. This intervention is based on a combination of evidence-based approaches such as cognitive behavioral therapy, mindfulness, and positive psychology techniques. The targeted symptomatology was evaluated using the Patient Health Questionnaire-9, Generalized Anxiety Disorder-7, and Barkley Adult ADHD Rating Scale-IV. Quality of life aspects were evaluated using the Satisfaction With Life Scale and the Life Satisfaction Questionnaire, and user feedback surveys were used to assess user experience and acceptability.

RESULTS

The study retention rate was 97% (29/30), and high engagement levels were observed, as depicted by the 69 minutes spent on the app per week, 5 emotion logs per week, and 11.5 mental health actions per week. An average decrease of 46.2% (P<.001; r=0.89) in depressive symptoms and 46.4% (P<.001; r=0.86) in anxiety symptoms was observed, with clinically significant improvement for more than half (17/30, 57% and 18/30, 60%, respectively) of the participants. This was followed by an average increase of 23% (P<.001; r=0.78) and 20% (P=.003; r=0.8) in Satisfaction With Life Scale and Life Satisfaction Questionnaire scores, respectively. The overall participant satisfaction level was 4.3 out of 5.

CONCLUSIONS

The findings support the feasibility, acceptability, and value of the examined digital program for adults with ADHD symptomatology to address the coexisting depressive or anxiety symptoms. However, controlled trials with larger sample sizes and more diverse participant profiles are required to provide further evidence of clinical efficacy.

Magnitude, relationship and determinants of attention deficit hyperactivity disorder and depression among University of Gondar undergraduate students, Northwest Ethiopia, 2022: Non-recursive structural equation modeling

BACKGROUND

Up to 80% of adults with attention deficit hyperactivity disorder (ADHD) may have a concomitant psychiatric disorder. ADHD and depression, combined with the demands of University life, can pose serious challenges for students. However, there are limited studies conducted on this topic in our country. Therefore, the current study assessed the magnitude, relationship, and determinants of ADHD and depressive symptoms among students at the University of Gondar.

METHOD

An institution-based cross-sectional study was employed among 1514 undergraduate students at the University of Gondar from June 1-20, 2022. A stratified, simple random sampling technique was applied. Structural equation modeling was employed. The degree of relationship was interpreted based on the adjusted regression coefficient with 95% confidence interval (CI) and p-value (<0.05).

RESULT

In our study, 37.6% [CI: 35.2-40.1%] and 20.01% [CI: 18.1-22.1%] of the participants had depressive and ADHD symptoms, respectively. Chronic illness [β = 0.19, CI; 0.09, 0.30], alcohol use [β = 0.10, CI; 0.03, 0.17], social support [β = -0.23, CI; -0.29, -0.17], problematic internet use (PIU) [β = 0.23, CI; 0.18, 0.27], and insomnia [β = 0.24, CI; 0.17, 0.30] had a direct relationship with depressive symptoms. Mother education level [β = -0.09, CI; -0.13, -0.06], birth order [β = -0.09, CI; -0.11, -0.07], chat chewing [β = 0.18, CI; 0.06, 0.30], and depressive symptoms [β = 0.73, CI; 0.62, 0.86] had a direct relationship with ADHD. Chronic illness [β = 0.14, CI; 0.06, 0.22], PIU [β = 0.16, CI; 0.13, 0.21], social support [β = -0.16, CI; -0.22, -0.12], and insomnia [β = 0.17, CI; 0.13, 0.23] had an indirect effect on ADHD.

CONCLUSION AND RECOMMENDATION

The prevalence of ADHD and depressive symptoms was high. Chronic disease, alcohol use, social support, PIU, and insomnia had a direct effect on depressive symptoms and an indirect effect on ADHD. Mother education, birth order, chat chewing, and depressive symptoms had a direct effect on ADHD. Our study provided useful clues for clinical treatment and school-based interventions that aim to improve college students' mental well-being. It is better to design school-based intervention and prevention programs to achieve timely diagnosis and treatment of these disorders among university students.

Bidirectional associations between maladaptive cognitions and emotional symptoms, and their mediating role on the quality of life in adults with ADHD: a mediation model

Background/objectives

Adults with attention-deficit/hyperactivity disorder (ADHD) have more maladaptive cognitions, emotional problems and a poorer quality of life (QoL). A verification of the psychological model in clinical samples is needed for a better understanding of the mechanisms of ADHD diagnosis on QoL via maladaptive cognitions, emotional symptoms, and their interactions.

Methods

299 ADHD participants and 122 healthy controls were recruited. ADHD core symptoms, maladaptive cognitions, emotional symptoms and psychological QoL were rated. Pearson's correlation and structural equation modeling were analyzed to explore the relationship and influence of ADHD diagnosis on QoL.

Results

More maladaptive cognitions, emotional symptoms, and poorer QoL were found in the ADHD group, and the dysfunctional attitudes were on par between ADHD with or without medication (p = 0.368). Moderate to strong correlations were found between emotional symptoms, maladaptive cognitions and QoL, and ADHD core symptoms presented correlations among the above scores (r = 0.157 ~ 0.416, p < 0.01) in ADHD participants. The influence of ADHD diagnosis on QoL was mediated through maladaptive cognitions, emotional symptoms, and their bidirectional interactions (p < 0.05), especially those with stable medication.

Conclusion

Our study is the first to verify the psychological model in adults with ADHD in China. The findings determined the direct influence of ADHD diagnosis on QoL and the indirect influence through maladaptive cognitions, emotional symptoms, and their interactions, emphasizing the importance of interventions for emotional symptoms and maladaptive cognitions for ADHD patients both with or without medication for a better QoL outcome.

Antibiotics modulate frequency and early generation of epileptic seizures in zebrafish

Antibiotics have been used for decades to treat various bacterial infections. Apart from bactericidal activities, their potential side effects have not been much studied or evaluated. Neurotoxicity is a major concern in the case of β-lactam and fluoroquinolone families, which can result in convulsions or seizures. Here, we proposed a hypothesis to check whether antibiotic treatment can conclusively enhance anxiety-like behaviours and how seizure behavioural profile gets modulated in pentylenetetrazole (PTZ)-treated zebrafish. Zebrafish were treated with selected antibiotics such as 25 mg/L Penicillin G (PG) and Ciprofloxacin (CPFX), for 7 days and thereafter exposed to PTZ (7.5 mM) for 20 min. The data indicate that PG and CPFX-treated groups exhibited anxiety-like or stressed behavioural phenotypes in the novel tank test (6 min), and also, they were found to promote hyperactivity. Early onset of PTZ-induced seizure-like behavioural scores, the heightened intensity of seizure and reduced latency in different scores were found in PG and CPFX-administered groups. This study substantiates that PG and CPFX as potential seizure modulators in zebrafish. The zebrafish is a well-established and still expanding model organism in many fields. Here, we again reinforce zebrafish as a prominent model to investigate seizure-like neuro-behavioural entities and confirm that chronic antibiotic use has negative consequences that can exacerbate the circumstances of vertebrate species exhibiting seizure-related reactions.

Efficacy of cognitive behavioural therapy in medicated adults with attention-deficit/hyperactivity disorder in multiple dimensions: a randomised controlled trial

The study aimed to evaluate the efficacy of group cognitive behavioural therapy (CBT) in medicated adults with attention-deficit/hyperactivity disorder (ADHD) with a multidimensional evaluation and follow-up to week 36. Ninety-eight adult ADHD were randomly allocated to the CBT combined with medication (CBT + M) group or the medication (M) only group. The primary endpoint was the ADHD-Rating Scale (ADHD-RS). Secondary endpoints included emotional symptoms, self-esteem, automatic thoughts, quality of life (QoL), and executive function (EF). The outcome measures were obtained at baseline (T1), after the 12-week CBT treatment (T2), and at two follow-up time points (week 24, T3, and week 36, T4). Compared to the M-only group, the patients in the CBT + M group showed an overall significantly greater reduction from baseline in ADHD core symptoms (ADHD-RS total score at T3, and inattention subscale at T2 and T3), depression and anxiety symptoms (T2-T4), state anxiety (T2 and T3) and trait anxiety (T2), automatic thoughts questionnaire at T3, and QoL (physical domain, psychological domain, and social domain, most significant at T3 and weakened at T4). These findings further confirmed the efficacy of CBT on multiple dimensions and verified improvements in automatic thinking in adult ADHD. The superiority of the combination treatment mainly manifested in reduced inattention, emotional symptoms, and maladaptive thoughts and improved QoL. Trial registration number ChiCTR1900021705 (March-05-2019).

Depressive symptoms in youth with ADHD: the role of impairments in cognitive emotion regulation

Youth with attention-deficit/hyperactivity disorder (ADHD) are at increased risk to develop co-morbid depression. Identifying factors that contribute to depression risk may allow early intervention and prevention. Poor emotion regulation, which is common in adolescents, is a candidate risk factor. Impaired cognitive emotion regulation is a fundamental characteristic of depression and depression risk in the general population. However, little is known about cognitive emotion regulation in youth with ADHD and its link to depression and depression risk. Using explicit and implicit measures, this study assessed cognitive emotion regulation in youth with ADHD (N = 40) compared to demographically matched healthy controls (N = 40) and determined the association with depressive symptomatology. As explicit measure, we assessed the use of cognitive emotion regulation strategies via self-report. As implicit measure, performance in an ambiguous cue-conditioning task was assessed as indicator of affective bias in the processing of information. Compared to controls, patients reported more frequent use of maladaptive (i.e., self-blame, catastrophizing, and rumination) and less frequent use of adaptive (i.e., positive reappraisal) emotion regulation strategies. This pattern was associated with the severity of current depressive symptoms in patients. In the implicit measure of cognitive bias, there was no significant difference in response of patients and controls and no association with depression. Our findings point to depression-related alterations in the use of cognitive emotion regulation strategies in youth with ADHD. The study suggests those alterations as a candidate risk factor for ADHD-depression comorbidity that may be used for risk assessment and prevention strategies.

Self-management training vs. neurofeedback interventions for attention deficit hyperactivity disorder: Results of a randomized controlled treatment study

OBJECTIVES

Neurofeedback (NF) and self-management training (SMT) may be viable treatment options for patients with attention deficit hyperactivity disorder (ADHD) if they alleviate core symptoms, enhance the patients' self-concept and improve their quality of life (QoL). Aim of the current study is evaluating both interventions accordingly and to test whether specific improvements in core symptoms lead to more general improvements in self-concept and QoL.

METHODS

In a psychotherapeutic outpatient clinic in Germany, a total of N = 139 children with ADHD were screened for eligibility, of which 111 fulfilled inclusion criteria and participated in the study in accordance with the CONSORT 2010 statement. These were randomly assigned to NF vs. SMT interventions. Changes from pre- to post-intervention in core ADHD symptoms relying on parent and teacher reports (CONNERS 3) and objective tests (Qb-Test) as well as self-concept (interview with the children) and QoL assessments (using the KINDL-R self-report) were compared between patients receiving NF or SMT.

RESULTS

Significant improvements in ADHD symptoms were achieved similarly in both treatment groups, whilst QoL and self-concept improved after SMT only.

CONCLUSION

This treatment study provides further evidence that SMT and NF may reduce core symptoms, but SMT may also improve patients' self-concept and QoL and may thus in its current form be the favorable treatment option in naturalistic settings. However, several limitations of the current study implicate that further research is required before definitive conclusions and recommendations for clinical practice can be given.

CLINICAL TRIAL REGISTRATION

[www.clinicaltrials.gov], identifier [NCT01879644].

The Moderating Effect of Attention-Deficit Hyperactivity Disorder Symptoms on the Relationship Between Procrastination and Internalizing Symptoms in the General Adult Population

Background: The symptoms of attention-deficit hyperactivity disorder (ADHD) are known to exacerbate the effect of cognitive-behavioral impairments on emotional burden. Although adults with ADHD frequently experience procrastination and internalizing symptoms such as depression and anxiety, few studies have examined whether the association between procrastination and internalizing symptoms differs by ADHD symptoms. Objective: This study aimed to examine the moderating effect of ADHD symptoms on the association between procrastination and internalizing symptoms. Method: A cross-sectional survey was conducted among 470 adults (mean age=26.57, standard deviation=2.93) using self-reported questionnaires: Adult ADHD Self-Report Scale, General Procrastination Scales, Patient Health Questionnaire-9, and State-Trait Anxiety Inventory. Conclusion: Participants with more substantial ADHD symptoms experienced more procrastination and internalizing symptoms than those with the less substantial ADHD symptoms. Therefore, procrastination constitutes the treatment target for those suffering from ADHD and comorbid internalizing symptoms. Alternatively, there was no enhancing effect of ADHD symptoms on the association between procrastination and internalizing symptoms. It is necessary to examine more precise and valid hypotheses and underlying mechanisms of procrastination in high and low ADHD symptom groups.

Exploring the Effects of Pharmacological, Psychosocial, and Alternative/Complementary Interventions in Children and Adolescents With Attention-Deficit/Hyperactivity Disorder: Meta-Regression Approach

BACKGROUND

There have been various therapies for attention-deficit/hyperactivity disorder (ADHD), but the previous meta-analysis of ADHD efficacy remains unclear. This study aims to systemically meta-regress the effect sizes (ES) of psychostimulant pharmacotherapy (methylphenidate and lisdexamfetamine), non-stimulant pharmacotherapy (atomoxetine and alpha-2 agonists), psychosocial therapy (parental behavioral therapy [PBT]), combination therapy (psychostimulant plus PBT), and alternative/complementary interventions to determine the right treatment for ADHD.

METHODS

We searched various ADHD interventions from the MEDLINE and PubMed databases (National Center for Biotechnology Information) between January 1, 1980, and July 30, 2018. Following the meta-analysis of random effects, the meta-regression analyses were used to explore factors potentially influencing treatment efficacy. The confounding variables included type of treatment, type of study, age, type of symptom scale used, and year of publication.

RESULTS

A total of 107 trials (n = 9883 participants) were included. After adjustment, compared with the psychostimulant therapy (28 trial, 2134 participants), non-stimulant pharmacotherapy (28 trials, 4991 participants) and alternative/complement intervention (25 trials, 1195 participants) were less effective by the ES of -0.384 (P = .004) and -0.419 (P = .028), respectively. However, compared with psychostimulant, PBT (19 trials, 1122 participants; ES = -0.308, P = .095) and the combination of psychostimulant and PBT (7 trials, 441participants; ES = -0.196, P = .209) did not differ significantly.

CONCLUSIONS

Psychostimulant therapy surpassed non-stimulant pharmacotherapy and alternative/complement intervention. Psychostimulant therapy, PBT, and the combination of psychostimulant therapy and PBT appear to be similar in efficacy according to this meta-regression.

Maternal depressive and anxiety symptoms and the risk of attention deficit hyperactivity disorder symptoms in offspring aged 17: Findings from the Raine Study

BACKGROUND

While previous studies have suggested that maternal anxiety and depressive symptoms are associated with increased risk of attention-deficit/hyperactivity disorder (ADHD) in their offspring in early and late childhood, studies exploring the risk in late adolescence are however lacking. This study aims to examine the association between maternal anxiety and depressive symptoms and the risk of ADHD symptoms in late adolescence (at age 17).

METHODS

We used data from the Raine Study. Maternal depressive and anxiety symptoms were measured when the child was 10 years of age using the Depression, Anxiety, and Stress Scale (DASS). Offspring ADHD symptoms at age 17 were assessed using the DSM-oriented scales of the child behavior checklist (CBCL). Log-binomial regression was used to explore the associations.

RESULTS

We found an increased risk of ADHD symptoms in offspring of mothers with comorbid anxiety and depressive symptoms when compared with offspring of mothers with no symptoms [RR 5.60 (95%CI 3.02-10.37)]. There was a nearly three-fold increase in the risk of ADHD symptoms in offspring of mothers with increased anxiety symptoms compared with offspring of mothers who were in the normal range [RR 2.84 (95%CI 1.18-6.83)]. No association was observed with maternal depressive symptoms.

CONCLUSION

This study found an increased risk of ADHD symptoms in the offspring of mothers with anxiety as well as comorbid anxiety and depressive symptoms but not among the offspring of mothers with depressive symptoms. Early screening and intervention for ADHD symptoms in offspring with maternal anxiety and comorbid anxiety and depressive symptoms are warranted.

Is Attention-Deficit/Hyperactivity Disorder a Risk Syndrome for Parkinson's Disease?

Recent epidemiological evidence indicates that diagnosis of attention-deficit/hyperactivity disorder (ADHD) is associated with increased risk for diseases of the basal ganglia and cerebellum, including Parkinson's disease (PD). The evidence reviewed here indicates that deficits in striatal dopamine are a shared component of the causal chains that produce these disorders. Neuropsychological studies of adult ADHD, prodromal PD, and early-stage PD reveal similar deficits in executive functions, memory, attention, and inhibition that are mediated by similar neural substrates. These and other findings are consistent with the possibility that ADHD may be part of the PD prodrome. The mechanisms that may mediate the association between PD and ADHD include neurotoxic effects of stimulants, other environmental exposures, and Lewy pathology. Understanding the nature of the association between PD and ADHD may provide insight into the etiology and pathogenesis of both disorders. The possible contribution of stimulants to this association may have important clinical and public health implications.

Risk Factors for Depression in Adolescents With ADHD: The Impact of Cognitive Biases and Stress

Objective: Youth diagnosed with ADHD are at heightened risk of depression. However, many do not develop depression. Individuals with specific cognitive biases are more likely to develop depression yet it remains untested whether these vulnerability-stress models apply to depression risk in youth with ADHD. Method: We examined whether interpretation and attention biases moderated the relation between stressful life events and depressive symptoms in a sample of adolescents (M_age = 14.42) with ADHD (n = 59) and without ADHD (n = 36). Results: Youth with ADHD experienced more stressful life events compared with those without ADHD. Interpretation biases moderated the association between stress and depressive symptoms in youth with and without ADHD. Attention biases moderated the association between stress and depressive symptoms in the non-ADHD youth only. Conclusion: These results enhance our understanding of vulnerability for depression in adolescence with ADHD and inform targeted prevention and treatment models during this critical developmental juncture.

Cognitive mechanisms underlying depressive disorders in ADHD: A systematic review

The risk for major depressive disorder (MDD) is considerably increased in young adults with attention-deficit/hyperactivity disorder (ADHD) but underlying mechanisms are poorly understood. This review explores ADHD-specific neurocognitive impairments as possible underlying mechanisms for ADHD-depression comorbidity. Two systematic literature searches were conducted in EBSCOhost, PubMED, and Cochrane Reviews databases according to PRISMA guidelines. The first search identified 18 meta-analyses of cross-sectional and longitudinal studies on cognitive dysfunctions in MDD across the lifespan. The second search identified six original studies on reaction time variability in MDD. During acute depression, children and adults showed cognitive deficits that overlapped with some of the ADHD-related impairments. Findings from remitted patients, high-risk individuals, and few prospective studies suggest that a subset of these shared impairments, specifically executive dysfunctions (selective attention, verbal fluency, working memory) and long-term memory problems, are candidate pre-existing risk markers of depression. We discuss if and how these specific neurocognitive mechanisms may mediate developmental pathways from ADHD to depression. If replicated by longitudinal studies, these findings may guide future prevention strategies.

The Effects of Family Transitions on Depressive Symptoms: Differences among Young Adults with and without Childhood Symptoms of Attention-Deficit/ Hyperactivity Disorder

Attention-deficit/hyperactivity disorder (ADHD) is tied to higher levels of depression, but the social factors that shape these associations are not well understood. This study considers whether family transitions affect depressive symptoms differently for young adults with and without childhood symptoms of ADHD at subthreshold or diagnostic levels. Between-within regression analysis of nationally representative longitudinal survey data shows that transitions into cohabitation and parenthood affect depressive symptoms differently for young adults with and without childhood symptoms of ADHD. Specifically, within-person effects indicate that transitions into cohabitation and parenthood are tied to decreases in depressive symptoms, but only for young adults without childhood symptoms of ADHD. In contrast, transitions into marriage are tied to decreases in depressive symptoms, and transitions out of coresidential unions are tied to increases in depressive symptoms, regardless of childhood symptoms of ADHD. The results suggest that some family transitions may work to widen ADHD disparities in depression, under-scoring the importance of family contexts for shaping mental health throughout the life course.

Attention-deficit/hyperactivity disorder (ADHD) symptoms and suicidality in children: The mediating role of depression, irritability and anxiety symptoms

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is associated with increased suicidality risk. Yet, potential mechanisms transmitting the effect of ADHD to suicidality remain unclear. We investigated whether depression, irritability and anxiety symptoms mediate between ADHD symptoms and suicidality.

METHODS

ADHD, depression, irritability and anxiety symptoms as well as suicidality (composited of suicidal ideation, attempts or self-harm) were measured in an outpatient clinic for ADHD (N = 1,516, 6-17 years old, 61.1% diagnosed with ADHD) using parent and teacher questionnaires. Multiple mediator models adjusted for age, sex and psychosocial adversities were constructed separately for parent- and teacher-report.

RESULTS

Parents reported higher rates of suicidality than did teachers (12.1% and 3.8%, p < .001). Suicidality was associated with parent (OR = 1.10, 95%CI: 1.07-1.14) and teacher (OR = 1.08, 95%CI: 1.03-1.15) reported ADHD symptoms. The association between ADHD symptoms and suicidality was mediated by both parent- and teacher-reported depression (39.1% and 45.3% of total effect, respectively) and irritability symptoms (36.8% and 38.4% of total effect, respectively). Anxiety symptoms mediated between ADHD and suicidality for parent- but not teacher-report (19.0% of total effect). No direct effect of ADHD symptoms was found once depression, irritability and anxiety were controlled.

LIMITATIONS

The cross-sectional design limits the ability to determine causal order between mediators and outcome.

CONCLUSIONS

Our results confirmed the association between ADHD symptoms and suicidality. However, this association was indirect and fully mediated by symptoms of depression, irritability and anxiety. Assessing these symptoms may enable an estimate of suicidality and help managing suicidal risk in ADHD.

Prefrontal cortex inflammation and liver pathologies accompany cognitive and motor deficits following Western diet consumption in non-obese female mice

AIMS

The high sugar and lipid content of the Western diet (WD) is associated with metabolic dysfunction, non-alcoholic steatohepatitis, and it is an established risk factor for neuropsychiatric disorders. Our previous studies reported negative effects of the WD on rodent emotionality, impulsivity, and sociability in adulthood. Here, we investigated the effect of the WD on motor coordination, novelty recognition, and affective behavior in mice as well as molecular and cellular endpoints in brain and peripheral tissues.

MAIN METHODS

Female C57BL/6 J mice were fed the WD for three weeks and were investigated for glucose tolerance, insulin resistance, liver steatosis, and changes in motor coordination, object recognition, and despair behavior in the swim test. Lipids and liver injury markers, including aspartate-transaminase, alanine-transaminase and urea were measured in blood. Serotonin transporter (SERT) expression, the density of Iba1-positive cells and concentration of malondialdehyde were measured in brain.

KEY FINDINGS

WD-fed mice exhibited impaired glucose tolerance and insulin resistance, a loss of motor coordination, deficits in novel object exploration and recognition, increased helplessness, dyslipidemia, as well as signs of a non-alcoholic steatohepatitis (NASH)-like syndrome: liver steatosis and increased liver injury markers. Importantly, these changes were accompanied by decreased SERT expression, elevated numbers of microglia cells and malondialdehyde levels in, and restricted to, the prefrontal cortex.

SIGNIFICANCE

The WD induces a spectrum of behaviors that are more reminiscent of ADHD and ASD than previously recognized and suggests that, in addition to the impairment of impulsivity and sociability, the consumption of a WD might be expected to exacerbate motor dysfunction that is also known to be associated with adult ADHD and ASD.

Language of ADHD in Adults on Social Media

Objective: We computationally analyze the language of social media users diagnosed with ADHD to understand what they talk about, and how their language is correlated with users' characteristics such as personality and temporal orientation. Method: We analyzed approximately 1.3 million tweets written by 1,399 Twitter users with self-reported diagnoses of ADHD, comparing their posts with those used by a control set matched by age, gender, and period of activity. Results: Users with ADHD are found to be less agreeable, more open, to post more often, and to use more negations, hedging, and swear words. Posts are suggestive of themes of emotional dysregulation, self-criticism, substance abuse, and exhaustion. A machine learning model can predict which of these Twitter users has ADHD with an out-of-sample AUC of .836. Conclusion: Based on this emerging technology, conjectures of future uses of social media by researchers and clinicians to better understand the naturalistic manifestations and sequelae of ADHD.

Development and Evaluation of the ADHD Cognitions Scale for Adults

Objective: The clinical literature on ADHD in adults suggests that "overly positive" or optimistic cognitions may contribute to impairment and failure to use self-regulation skills in this population, yet the research literature on this topic is limited. We developed the ADHD Cognitions Scale (ACS), a brief self-report measure of ADHD-related thoughts, and evaluated its psychometric properties. Method: We collected self-report measures, inculding the ACS, from two large community samples (Ns = 262, 304). Results: The measure demonstrated a one-factor solution that replicated in the second sample. Evidence of good internal consistency and also convergent and divergent validity was obtained for both samples. Scores on the ACS correlated with functional impairment, time management problems, and avoidant coping strategies. Conclusion: With additional study, the ACS may be useful to identify and track maladaptive ADHD-related cognitions during cognitive-behavioral treatment, and to further study the role of these thoughts in ADHD-related impairment.

Examining the Rate of Self-Reported ADHD-Related Traits and Endorsement of Depression, Anxiety, Stress, and Autistic-Like Traits in Australian University Students

OBJECTIVE

To investigate the rate of ADHD-related traits among young adults in an Australian university, and to examine whether higher endorsement of ADHD-related symptoms is associated with self-reported symptoms of depression, anxiety, distress, and autistic-like traits.

METHOD

In total, 1,002 students aged 17 to 25 years completed the Conners' Adult ADHD Rating Scale (CAARS), the Depression, Anxiety, and Stress Scale (DASS), and the Autism Quotient (AQ).

RESULTS

About 17.3% of students reported "at-risk" levels of ADHD-related symptoms. Regression analyses revealed that CAARS scores explained unique variance in self-reported levels of depression, anxiety, stress, and autism-related traits.

CONCLUSION

The rate of self-reported ADHD symptoms is higher in Australian undergraduate students than that reported in previous studies using the CAARS to investigate rates of diagnosed students. Problems with self-concept accounted for the most unique variance in DASS subscale scores. Hyperactivity/restlessness and inattention/memory problems accounted for the most unique variance in AQ-Social and AQ-Attention-to-Detail scores, respectively.

Compassionate Hearts Protect Against Wandering Minds: Self-compassion Moderates the Effect of Mind-Wandering on Depression

Depression is associated with high levels of mind-wandering and low levels of self-compassion. However, little is known about whether and how these two factors interact with one another to influence depressive symptoms. The current study examined the interaction between mind-wandering, self-compassion and depressive symptoms in a depressed sample and tested the effects of an eight-week Mindfulness Based Cognitive Therapy (MBCT) program on these constructs. At baseline, mind-wandering was associated with higher depressive symptoms only among individuals with low self-compassion. Self-compassion additionally predicted depressive improvement. As expected, MBCT increased self-compassion and reduced mind-wandering compared to a treatment-as-usual control group. Overall, longitudinal changes in self-compassion produced a moderation effect similar to the one at baseline so that increases in mind-wandering were associated with increases in depressive symptoms only among those who decreased in self-compassion. Results provide the first evidence that self-compassion can protect against the deleterious effects of mind-wandering among depressed participants, both at baseline and longitudinally. Findings also suggest that self-compassion is an effective predictor of depressive improvement. Finally, MBCT is effective not only at reducing depressive symptoms, but also at targeting protective and risk factors associated with depression.

Investigating Resilience to Depression in Adults With ADHD

OBJECTIVE

ADHD is associated with elevated rates of comorbid depressive disorders, yet the nature and development of this comorbidity remain understudied. We hypothesized that a longer period of prior ADHD treatment, being less likely to engage in maladaptive cognitive/behavioral coping strategies, and less severe ADHD symptoms would predict greater likelihood of lifetime resilience to depression.

METHOD

Seventy-seven adults with ADHD completed diagnostic interviews, clinician-administered symptom rating scales, a stressful life events measure, and self-report questionnaires. We used logistic regression analyses to identify factors associated with resilience to depression.

RESULTS

Adults with more extensive ADHD treatment histories were more likely to be resilient to depression. Those who were less likely to report ruminative thinking patterns and cognitive-behavioral avoidance were also more resilient. Severity of current or childhood ADHD symptoms and recent negative life events did not predict resilience.

CONCLUSION

Results identify protective factors that may promote the resiliency to ADHD-depression comorbidity.

Depressive symptoms and the role of affective temperament in adults with attention-deficit/hyperactivity disorder (ADHD): A comparison with bipolar disorder

OBJECTIVES

To investigate the characteristics of depressive symptoms and the influence of affective temperament in adults with attention-deficit/hyperactivity disorder (ADHD), in comparison with bipolar disorder (BD) patients and healthy controls (HCs).

METHOD

Sixty patients with ADHD, 50 patients with BD, and 30 HCs were assessed with instruments for measuring depressive symptoms (Beck Depression Inventory-II), and affective temperaments (Temperament Scale of Memphis, Pisa and San Diego, self-administered version; TEMPS-A). In addition, participants were evaluated with scales for measuring ADHD symptoms, impulsiveness, anxiety, executive dysfunction, and quality of life.

RESULTS

ADHD patients showed levels of depressive symptoms similar to BD patients and higher than HCs. Only neurovegetative symptoms of depression differentiated ADHD and BD groups (BD > ADHD). Depressive symptoms in ADHD patients correlated positively with core ADHD, impulsivity, anxiety, and dysexecutive symptoms and negatively with quality of life. Thirty-eight percent of patients with ADHD scored above the cutoff for at least one affective temperament. Cyclothymic was the more common affective temperament (25%). ADHD patients with affective temperamental traits were more depressed and impulsive than patients without those traits and showed a symptomatic profile analogous to BD patients.

LIMITATIONS

The small size of resultant samples when ADHD group was stratified by the presence of affective temperament. In addition, results may not generalize to less severe ADHD patients from the community.

CONCLUSIONS

Concomitant depressive symptoms constitute a common occurrence in adults with ADHD that carries significant psychopathological and functional consequences. The concept of affective temperaments may be an interesting link for explaining depressive symptomatology and emotional impulsivity in a subgroup of patients with ADHD, beyond the classic idea of comorbidity.

Adult ADHD and comorbid disorders: clinical implications of a dimensional approach

Attention-deficit/hyperactivity disorder (ADHD) in the adult population is frequently associated with comorbid psychiatric diseases that complicate its recognition, diagnosis and management.The prevalence of ADHD in the general adult population is 2.5% and it is associated with substantial personal and individual burden. The most frequent comorbid psychopathologies include mood and anxiety disorders, substance use disorders, and personality disorders. There are strong familial links and neurobiological similarities between ADHD and the various associated psychiatric comorbidities. The overlapping symptoms between ADHD and comorbid psychopathologies represent challenges for diagnosis and treatment. Guidelines recommend that when ADHD coexists with other psychopathologies in adults, the most impairing condition should generally be treated first.Early recognition and treatment of ADHD and its comorbidities has the potential to change the trajectory of psychiatric morbidity later in life. The use of validated assessment scales and high-yield clinical questions can help identify adults with ADHD who could potentially benefit from evidence-based management strategies.

Self-Reported Mindful Attention and Awareness, Go/No-Go Response-Time Variability, and Attention-Deficit Hyperactivity Disorder

The abilities to stabilize the focus of attention, notice attention lapses, and return attention to an intended object following lapses are precursors for mindfulness. Individuals diagnosed with attention-deficit hyperactivity disorder (ADHD) are deficient in the attentional and self-control skills that characterize mindfulness. The present study assessed the relationship between mindfulness and ADHD in young adults using the Mindful Attention and Awareness Scale (MAAS), a computerized Go/No-Go task (the Test of Variables of Attention (TOVA)), the World Health Organization Adult Self-Report Scale (ASRS), a tool used as an adult ADHD screen, the Beck Anxiety Inventory (BAI), and the Beck Depression Inventory-II (BDI-II). We recruited 151 adult volunteers (ages 18 to 40); 100 with confirmed ADHD diagnoses and 51 control participants. Overall, participants with prior diagnoses of ADHD scored lower on the MAAS than controls and ASRS scores were strongly negatively correlated MAAS scores. Attention performance index, response time, and response-time variability subscales of the TOVA were positively correlated with MAAS scores and negatively correlated with ASRS scores. Intrasubject response-time variability on the TOVA, a parameter associated with attention lapses, was also strongly negatively correlated with MAAS scores. Overall, participants' self-reported mindfulness, as measured by the MAAS, was strongly related to self-reports on a clinical measure of attention disorders, anxiety, depression, and multiple indices of concentration and mind wandering on a standardized Go/No-Go task, the TOVA.

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.

Assessment of the relationship between self-reported cognitive distortions and adult ADHD, anxiety, depression, and hopelessness

The current chart review study examined the relationship between self-reported cognitive distortions, attention-deficit/hyperactivity disorder (ADHD) symptoms, and co-occurring symptoms of depression and anxiety in a clinical sample of adults diagnosed with ADHD. Thirty subjects completed inventories measuring cognitive distortions, ADHD, anxiety, depression, and hopelessness as part of the standard diagnostic evaluation protocol used in a university-based outpatient clinic specializing in adult ADHD. A series of correlational analyses were conducted to assess the relationship between self-reported cognitive distortions, ADHD, anxiety, depression, and hopelessness. Results indicated a significant, positive correlation between self-reported cognitive distortions and ADHD. Responses to individual items on the measure of cognitive distortions were tabulated to identify the prevalence of specific cognitive distortion categories, with Perfectionism emerging as the most frequently endorsed. Further clinical implications of these findings are discussed.

Development and Application of a Genetic Algorithm for Variable Optimization and Predictive Modeling of Five-Year Mortality Using Questionnaire Data

The problem of selecting important variables for predictive modeling of a specific outcome of interest using questionnaire data has rarely been addressed in clinical settings. In this study, we implemented a genetic algorithm (GA) technique to select optimal variables from questionnaire data for predicting a five-year mortality. We examined 123 questions (variables) answered by 5,444 individuals in the National Health and Nutrition Examination Survey. The GA iterations selected the top 24 variables, including questions related to stroke, emphysema, and general health problems requiring the use of special equipment, for use in predictive modeling by various parametric and nonparametric machine learning techniques. Using these top 24 variables, gradient boosting yielded the nominally highest performance (area under curve [AUC] = 0.7654), although there were other techniques with lower but not significantly different AUC. This study shows how GA in conjunction with various machine learning techniques could be used to examine questionnaire data to predict a binary outcome.

“Turning Intentions Into Actions”

Contemporary models of attention-deficit/hyperactivity disorder (ADHD) provide frameworks for understanding this condition that move beyond the diagnostic symptom criteria. ADHD is currently viewed as a developmental syndrome of impaired self-regulatory processes that underlie the common symptoms and functional problems. Most clinic-referred adults with ADHD report chronic difficulties executing their intended plans despite recognizing the negative consequences for not doing so. Seeing as the psychosocial treatments for adult ADHD intervene at the level of life impairments and functioning, it is important that interventions directly target these implementation problems. The goal of this article is to discuss the case of a young woman with ADHD who has difficulties engaging in the various tasks she needs to perform to pursue her post-college goals. In particular, a cognitive-behavioral therapy approach that emphasizes implementation strategies designed to help adults with ADHD follow through on their plans is illustrated.

Incautiously Optimistic: Positively-Valenced Cognitive Avoidance in Adult ADHD

Clinicians who conduct cognitive-behavioral therapy (CBT) targeting attention-deficit/hyperactivity disorder (ADHD) in adulthood have noted that their patients sometimes verbalize overly positive automatic thoughts and set overly optimistic goals. These cognitions are frequently related to failure to engage in compensatory behavioral strategies emphasized in CBT. In this paper, we offer a functional analysis of this problematic pattern, positively-valenced cognitive avoidance, and suggest methods for addressing it within CBT for adult ADHD. We propose that maladaptive positive cognitions function to relieve aversive emotions in the short-term and are therefore negatively reinforced but that, in the long-term, they are associated with decreased likelihood of active coping and increased patterns of behavioral avoidance. Drawing on techniques from Behavioral Activation (BA), we offer a case example to illustrate these concepts and describe step-by-step methods for clinicians to help patients recognize avoidant patterns and engage in more active coping.