Attention-deficit/hyperactivity disorder symptoms and suicidal behavior in adult psychiatric outpatients

Toward an Increased Attention on ADHD Symptoms and Traits in Young Adults: Prevalence Data From Screening Tools in a Psychiatric Outpatient Clinic

OBJECTIVE

to analyze the prevalence of ADHD symptoms and traits in a heterogeneous clinical psychiatric sample of young adults (aged 18-24 years old), who referred to a specialized outpatient clinic for various psychiatric and psychological disturbances.

METHOD

259 participants completed three validated self-report screening questionnaires for ADHD: the Wender Utah Rating Scale (WURS), the Adult Attention-Deficit/Hyperactivity Disorder Self-Report Screening Scale for DSM-5 (ASRS-5), and the Conners' adult ADHD rating scale (CAARS).

RESULTS

12.4% of our sample scored above the cut-off at both the WURS and the ASRS-5 and was considered at risk of ADHD.

CONCLUSION

the prevalence rate in our sample is higher than the one found in the adult general population (6.76%), and in the lower range of the one found in the adult clinical population (6.9%-38.8%). The potential role of sociodemographic (age, sex, gender identity, and employment) and comorbidity factors is discussed.

Autism in adult psychiatric out-patients: self-reported suicidal ideation, suicide attempts and non-suicidal self-injury

BACKGROUND

The prevalence of self-reported suicidal ideation, suicide attempts and non-suicidal self-injury (NSSI) remains unclear among adults with autism unrecognised in childhood who attend psychiatric services.

AIMS

We aimed to estimate the prevalence of suicidal ideation, suicide attempts and NSSI; identify factors associated with suicide attempts and NSSI; and describe NSSI in this group.

METHOD

Sixty-three new patients at an adult psychiatric out-patient clinic (57% women, mean age 32 years) who met full (n = 52) or subthreshold (two A criteria and minimum of two B criteria; n = 11) DSM-5 criteria for autism spectrum disorder were included in the study. Clinical assessments included overall diagnostic review, Paykel's questions on passive and active suicidality, evaluation of NSSI with the Functional Assessment of Self-Mutilation, and results of cognitive tests. One follow-up of medical records was made.

RESULTS

In this sample of psychiatric out-patients identified as first having autism in adulthood, almost a third (31%) of patients reported suicidal ideation during the past month, 86% had lifetime suicidal ideation and 25% reported at least one suicide attempt. Factors associated with suicide attempts included hazardous or harmful alcohol use and/or drug-related problems, and severity of depression. A total of 44% reported NSSI. Factors associated with NSSI were female sex, history of suicidal plans and antisocial personality disorder. Substance or alcohol use were often overlooked, especially in women.

CONCLUSIONS

Suicidal ideation, suicide attempts and NSSI were very common in adults with autism who were recently referred to an out-patient psychiatric service. Suicidal ideation and NSSI were more common than suicide attempts. Clinicians should always consider suicidal ideation and NSSI in adult psychiatric patients with autism.

Suicidal behavior across a broad range of psychiatric disorders

Suicide is a leading cause of death worldwide. In 2020, some 12.2 million Americans seriously contemplated suicide, 3.2 million planned suicide attempts, and 1.2 million attempted suicide. Traditionally, the approach to treating suicidal behavior (SB) has been to treat the "underlying" psychiatric disorder. However, the number of diagnoses associated with SB is considerable. We could find no studies describing the range of disorders reported to be comorbid with SB. This narrative review summarizes literature documenting the occurrence of SB across the lifespan and the full range of psychiatric diagnoses, not only BPD and those that comprise MDE, It also describes the relevance of these observations to clinical practice, research, and nosology. The literature searches contained the terms "suicid*" and each individual psychiatric diagnosis and identified 587 studies. We did not include case reports, case series, studies only addressing suicidal ideation or non-suicidal self-injury (NSSI), studies on self-harm, not distinguishing between SB and NSSI and studies that did not include any individuals that met criteria for a specific DSM-5 diagnosis (n = 366). We found that SB (suicide and/or suicide attempt) was reported to be associated with 72 out of 145 diagnoses, although data quality varied. Thus, SB is not exclusively germane to Major Depressive Episode (MDE) and Borderline Personality Disorder (BPD), the only conditions for which it is a diagnostic criterion. That SB co-occurs with so many diagnoses reinforces the need to assess current and past SB regardless of diagnosis, and supports the addition of charting codes to the DSM-5 to indicate current or past SB. It also comports with new data that specific genes are associated with SB independent of psychiatric diagnoses, and suggests that SB should be managed with specific suicide prevention interventions in addition to treatments indicated for co-occurring diagnoses. SB diagnostic codes would help researchers and clinicians document and measure SB's trajectory and response to treatment over time, and, ultimately, help develop secondary and tertiary prevention strategies. As a separate diagnosis, SB would preclude situations in which a potentially life-threatening behavior is not accounted for by a diagnosis, a problem that is particularly salient when no mental disorder is present, as is sometimes the case.

Anxiety, mood, and substance use disorders in adult men and women with and without Attention-Deficit/Hyperactivity Disorder: a substantive and methodological overview

Knowledge on psychiatric comorbidity in adult ADHD is essential for prevention, detection, and treatment of these conditions. This review (1) focuses on large studies (n> 10,000; surveys, claims data, population registries) to identify (a) overall, (b) sex- and (c) age-specific patterns of comorbidity of anxiety disorders (ADs), major depressive disorder (MDD), bipolar disorder (BD) and substance use disorders (SUDs) in adults with ADHD relative to adults without ADHD; and (2) describes methodological challenges relating to establishing comorbidity in ADHD in adults as well as priorities for future research. Meta-analyses (ADHD: n=550,748; no ADHD n=14,546,814) yielded pooled odds ratios of 5.0(CI:3.29-7.46) for AD, 4.5(CI:2.44-8.34) for MDD, 8.7(CI:5.47-13.89) for BD and 4.6(CI:2.72-7.80) for SUDs, indicating strong differences in adults with compared to adults without ADHD. Moderation by sex was not found: high comorbidity held for both men and women with sex-specific patterns as in the general population: higher prevalences of ADs, MDD and BD in women and a higher prevalence of SUDs in men. Insufficient data on different phases of the adult lifespan prevented conclusions on developmental changes in comorbidity. We discuss methodological challenges, knowledge gaps, and future research priorities.

Are attention-deficit/hyperactivity disorder symptoms associated with negative health outcomes in individuals with psychotic experiences? Findings from a cross-sectional study in Japan

Objective

Although research has indicated that the prevalence of attention-deficit/hyperactivity disorder (ADHD) may be elevated in individuals with psychotic disorders, as yet, there has been comparatively little research on this association and its effects among adults at the subclinical level. To address this deficit, the current study examined the association between psychotic experiences (PE) and ADHD symptoms in Japanese individuals and whether the presence of ADHD symptoms increases the risk for negative health outcomes in people with PE.

Method

Data were analyzed from an online sample of 1,452 individuals (age 18-89; 51.5% female) collected in 2021. Information on PE was obtained with the PRIME Screen-Revised (PS-R), while the Adult ADHD Self-Report Scale (ASRS) Screener was used to measure ADHD symptoms. Information was also obtained on a number of health outcomes including anxiety and depressive symptoms and suicidal ideation. Logistic regression was used to assess associations.

Results

In a fully adjusted analysis PE were associated with almost three times higher odds for ADHD symptoms (OR: 2.92, 95%CI: 1.19-7.17). In an analysis that was restricted to individuals with PE, ADHD symptoms were associated with significantly increased odds for depressive symptoms, lifetime suicidal ideation, perceived stress and severe sleep problems.

Conclusion

ADHD symptoms are present in some individuals with PE and increase the odds for several detrimental health outcomes in this population. Identifying co-occurring PE and ADHD/ADHD symptoms may facilitate treatment options and help prevent negative health outcomes in individuals with these conditions.

ADHD in Adults: A Systematic Review and Meta-Analysis of Prevalence Studies in Outpatient Psychiatric Clinics

OBJECTIVE

Systematic review and meta-analysis to estimate the pooled prevalence of ADHD in adult attendees of outpatient mental health clinics and to investigate factors influencing prevalence rates.

METHODS

The following were extracted: demographics, design of the study (screening only or two-phase), scales/criteria for diagnosis of ADHD, number of ADHD, and non-ADHD participants.

RESULTS

The pooled prevalence of ADHD from screening studies (n = 9) was 26.7%, (95% CI [17.2-37.4]), ADHD = 1727, No ADHD = 3,578. From studies employing a two-stage design (n = 5), prevalence was 14.61%, CI [10.39-19.41], ADHD = 561, No ADHD = 3,578. Age and gender did not have any significant effect on the estimated prevalence. By contrast exclusion of psychotic disorders lowers prevalence. The screening scale used also influence prevalence rates.

CONCLUSION

Meta-analysis shows high rates of adult ADHD among psychiatric outpatient clinics. Applying DSM-5 criteria increased prevalence rates. More methodologically robust studies, using two-stage design, need to be conducted to help assist in service planning.

ADHD prevalence in the psychiatric population

OBJECTIVE

This article presents a systematic literature review of the prevalence of Attention Deficit Hyperactivity Disorder (ADHD) in the adult psychiatric population.

METHODS

Three databases were searched using keywords relating to ADHD and psychiatric disorders. Fifteen studies published before May 2020 met inclusion criteria.

RESULTS

Prevalence rates ranged from 6.9 to 38.75%. There was considerable heterogeneity with regards to the assessment methods of ADHD and comorbidities, the sampling as well as inclusion and exclusion of psychiatric comorbidities. Research concluded that ADHD is underdiagnosed in this population. Gender ratios also varied between 1.8:1 and 1:2.5 (male:female).

CONCLUSIONS

All ADHD prevalence rates for the psychiatric population were considerably higher than the 2.8% estimated for the general adult population. ADHD should be kept in mind for psychiatric patients to ensure accurate diagnosis and optimal treatment options.Key PointsADHD is considerably underdiagnosed in the psychiatric populationGender ratios between 1.8:1 and 1:2.5 (male:female) reported in researchMore research is needed to ascertain if the use of ADHD screening instruments would improve the recognition and treatment of adult ADHD in the psychiatric population.

Attention-deficit/hyperactivity disorder symptoms, perceived stress, and suicidal ideation during the COVID-19 pandemic

OBJECTIVE

Attention-deficit/hyperactivity disorder (ADHD) symptoms have been linked to suicidal behavior. However, little is known about the mechanisms involved in this association. This study examined ADHD symptoms and suicidal ideation during the COVID-19 pandemic and the role of self-perceived stress in this association.

METHOD

Data were analyzed from an online sample of 1,452 Japanese individuals aged 18 to 89 obtained in February 2021. Information was collected on past-year suicidal ideation. ADHD symptoms were assessed with the Adult ADHD Self-Report Scale (ASRS) Screener while stress was measured with the Perceived Stress Scale (PSS-14). Depressive symptoms were assessed with the Patient Health Questionnaire (PHQ-9), while the Generalized Anxiety Disorder scale (GAD-7) was used to assess anxiety symptoms. Logistic regression was used to examine associations.

RESULTS

Fifty-one (3.5%) individuals had ADHD symptoms, while more than one in ten (11.7%) of the respondents reported past-year suicidal ideation. In an analysis adjusted for sociodemographic factors, ADHD symptoms were associated with eight times higher odds for past-year suicidal ideation. However, adjusting the analysis for mental health variables (anxiety and depressive symptoms) attenuated the association which became non-significant (odds ratio [OR]: 1.96, 95% confidence interval [CI]: 0.92-4.18). In contrast, in an analysis adjusted for mental health, individuals with ADHD symptoms and stress had significantly higher odds for suicidal ideation (OR: 3.72, 95%CI: 1.43-9.67) whereas, ADHD symptoms without stress were not linked to suicidal ideation (OR: 1.25, 95%CI: 0.38-4.18).

CONCLUSIONS

Self-perceived stress is important in the association between ADHD symptoms and suicidal ideation among individuals in Japan during the COVID-19 pandemic. Detecting and managing stress and its effects in individuals with ADHD/ADHD symptoms should be a therapeutic focus for improving health-related outcomes in this population both during the COVID-19 pandemic and beyond.

Fifteen years' experience with methylphenidate for attention-deficit disorder during pregnancy: Effects on birth weight, Apgar score and congenital malformation rates

BACKGROUND

Methylphenidate (MPD) is increasingly prescribed to fertile women with Attention-Deficit Disorder (AD(H)D), with or without hyperactivity, despite advice for discontinuation during pregnancy. Few studies report on results concerning safety after methylphenidate exposure during pregnancy for the offspring.

AIM

Safety for the offspring of exposure to MPD during pregnancy.

METHODS

This is an observational retrospective cohort study in a population of pregnant women and their offspring, treated with MPD for ADHD in the Psychiatry-Gynaecology-Pediatrics outpatient clinic between 1 January 2005 and 1 June 2020 at Isala hospital. The primary endpoints were birth weight and Apgar score in offspring exposed to MPD during pregnancy, compared to offspring unexposed to MPD. Birth weight was analysed using linear mixed model analysis. Apgar score and (secondary endpoint) neonatal malformations, at 20 week ultrasound, were analysed using basic univariate statistical analysis.

RESULTS

MPD continuation, compared to discontinuation, was associated with higher neonatal birth weight (p = 0.049), but lost statistical significance after incorporating covariates (p = 0.079). There were no significant differences in Apgar scores and congenital malformations between neonates exposed and unexposed to MPD.

CONCLUSIONS

MPD does not seem to affect birth weight, Apgar score and the frequency of neonatal malformations at the 20 week ultrasound.

Suicidality risk among adults with binge-eating disorder

OBJECTIVE

To estimate relative suicidality risk associated with binge-eating disorder (BED).

METHODS

Retrospective study of patients identified as having BED (N = 1042) and a matched general population cohort (N = 10,420) from the Optum electronic health record database between January 2009 and September 2015. Patients had ≥1 outpatient encounter with a provider who recognized BED during the 12-month baseline preceding entry date. Incidence and relative risk of suicidality were assessed.

RESULTS

Incidence per 1000 person-years (95% CI) of suicidal ideation and suicide attempts, respectively, was 31.1 (23.1, 41.0) and 12.7 (7.9, 19.4) in the BED cohort and 5.8 (4.7, 7.1) and 1.4 (0.9, 2.2) in the comparator cohort. Risk of suicidal ideation and suicide attempts was greater in the BED cohort (HR [95% CIs], 6.43 [4.42, 9.37]) than in the comparator cohort (HR [95% CI], 9.47 [4.99, 17.98]) during follow-up. After adjusting for psychiatric comorbidities, associations of suicidal ideation and suicide attempts with BED remained elevated in patients with BED having histories of suicidality.

CONCLUSIONS

Findings suggest that history of suicidality may result in an increased risk of suicidal ideation and suicide attempts in patients with BED relative to the general population. Psychiatric comorbidity burden may explain the elevated risk of these conditions in BED.

Suicidal behaviors and attention deficit hyperactivity disorder (ADHD): a cross-sectional study among Chinese medical college students

BACKGROUNDS

Associations between attention deficit hyperactivity disorder (ADHD) subtypes and suicidal behaviors remains unclear. The current study explored the prevalence of suicidal behaviors, and its association with ADHD among Chinese medical students.

METHODS

Five thousand six hundred ninety-three medical college students participated. Symptoms of suicidal behaviors, ADHD, anxiety, depression, tobacco and alcohol use were assessed using online questionnaires.

RESULTS

The prevalence of lifetime suicidal ideation, suicide plans, and suicide attempts among medical college students were 27.5, 7.9 and 14.8% respectively. Participants with ADHD predominantly inattentive type (ADHD-I) had more than fivefold increased odds of suicidal behaviors, the adjusted odds ratios (ORs) of ADHD-I and ADHD combined type (ADHD-C) remained significant after controlling for confounding factors.

CONCLUSIONS

ADHD is associated with high risk of suicidal behaviors. ADHD-I and ADHD-C were strongly associated with suicidal behaviors independent of comorbidities. The finding suggests the importance of addressing ADHD symptoms in suicide prevention.

Development of the Korean Practice Parameter for Adult Attention-Deficit/Hyperactivity Disorder

OBJECTIVES

Adult attention-deficit/hyperactivity disorder (ADHD) is an important mental health problem that needs resolution, especially considering the high rates of ADHD continuation from childhood to adolescence/adulthood and the high prevalence of ADHD in adults. Adults with ADHD have lifelong negative impacts and require close monitoring with long-term follow-up. Hence, the establishment of a Korean practice parameter for adult ADHD is necessary to minimize discontinuation of treatment and enable information sharing among Korean mental health professionals.

METHODS

The Korean practice parameter was developed using an evidence-based approach consisting of expert consensus survey coupled with literature review.

RESULTS

According to the expert consensus survey, the most commonly used diagnostic methods were clinical psychiatric interview (20.66%) and self-report scales (19.25%) followed by attention (14.71%) and psychological tests (14.24%). Key evaluation instruments currently available in Korea are the World Health Organization Adult ADHD Self-Report Rating Scale, Korean Adult ADHD Rating Scale, Diagnostic Interview for ADHD in Adults, Barkley Deficits in Executive Functioning Scale for adults, Comprehensive Attention Test, Conners' Continuous Performance Test, and the subtests of Wechsler Adult Intelligence Scale, Digit Span and Letter-Number Sequencing. Although pharmacotherapy is recommended as the first-line of treatment for adult ADHD, we recommend that it be followed by a multimodal and multidisciplinary approach including psychoeducation, pharmacotherapy, cognitive behavior therapy and coaching.

CONCLUSION

The Korean practice parameter introduces not only general information for the diagnosis and treatment of adult ADHD on a global scale, but also the process of diagnosis and treatment options tailored to the Korean population.

Suicidal and non-suicidal self-injurious behaviour in patients with bipolar disorder and comorbid attention deficit hyperactivity disorder after initiation of central stimulant treatment: a mirror-image study based on the LiSIE retrospective cohort

BACKGROUND

Currently, our understanding regarding treatment of adult attention deficit hyperactivity disorder (ADHD) co-occurring with bipolar disorder (BD) remains limited. The aim of this study was to evaluate the impact of central stimulant (CS) treatment on suicidal and non-suicidal self-injurious behaviour in patients with a pre-existing diagnosis of BD or schizoaffective disorder (SZD). Specifically, we tested the hypothesis that CS treatment significantly decreased the number of suicide attempts and non-suicidal self-injury events.

METHODS

A mirror-image study in patients with a dual diagnosis of BD or SZD and ADHD, comparing suicide attempts and non-suicidal self-injury events within 6 months and 2 years before and after CS initiation. This study was part of a retrospective cohort study (LiSIE) into effects and side-effects of lithium for maintenance treatment of BD as compared with other mood stabilisers.

RESULTS

Of 1564 eligible patients, 206 patients met the inclusion criteria. Within the 6 months after CS initiation, suicide attempts and non-suicidal self-injury events decreased significantly, both in terms of numbers of patients having such events (p = 0.013) and numbers of events experienced (p = 0.004). These effects were preserved 2 years after CS initiation.

CONCLUSIONS

CS treatment may reduce the risk of suicide attempts and non-suicidal self-injury events in patients with a dual diagnosis of BD or SZD and ADHD. Based on our findings, clinicians should not withhold CS treatment from patients with concomitant ADHD for fear of deterioration of the underlying BD. However, to minimise the risk of manic episodes concomitant mood stabiliser treatment and close monitoring remains warranted.

Sociodemographic and Clinical Characteristics of Transgender Adults in Australia

Background: Over the last 10 years, increases in demand for transgender health care has occurred worldwide. There are few data on clinical characteristics of Australian adult transgender individuals. Understanding gender identity patterns, sociodemographic characteristics, gender-affirming treatments, as well as medical and psychiatric morbidities, including neurobehavioral conditions affecting transgender and gender-diverse adults will help to inform optimal health service provision.

Purpose: In an Australian adult transgender cohort, we aimed to first, assess referral numbers and describe the sociodemographic and clinical characteristics, and second, to specifically assess the prevalence of autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD).

Methods: We performed a retrospective audit of deidentified electronic medical records in a primary care and a secondary care gender clinic in Melbourne, Australia. Annual referral rates, sociodemographic data, and prevalence of medical and psychiatric conditions were obtained.

Results: Data for 540 transgender individuals were available. Rapid rises were observed in referrals for transgender health services, more than 10 times the number in 2016 compared with 2011. Median age at initial presentation was 27 years (interquartile range (22, 36), range 16–74). Around 21.3% were unemployed and 23.8% had experienced homelessness despite high levels of education. Around 44.1% identified as trans male, 36.3% as trans female, and 18.3% as gender nonbinary. Medical morbidities were rare but mental illness was very common. The prevalence of depression was 55.7%, anxiety in 40.4%, ADHD in 4.3%, and ASD in 4.8%, all higher than reported age-matched general Australian population prevalence.

Conclusions: Rising demand for transgender care, socioeconomic disadvantage, and high burden of mental health conditions warrants a comprehensive multidisciplinary approach to provide optimal care for transgender individuals. Given that ASD and ADHD are prevalent, in addition to gender-affirming treatments, psychosocial interventions may assist individuals in navigating health care needs and to support social aspects of gender transition. Further studies are required to understand links between ASD, ADHD, and gender identity and to evaluate optimal models of health service provision for transgender individuals.