Medication adherence in psychopharmacologically treated adults with ADHD

Sign-tracking and goal-tracking in humans: Utilising eye-tracking in clinical and non-clinical populations

BACKGROUND

In Pavlovian conditioning, learned behaviour varies according to the perceived value of environmental cues. For goal-trackers (GT), the cue merely predicts a reward, whilst for sign-trackers (ST), the cue holds incentive value. The sign-tracking/goal-tracking model is well-validated in animals, but translational work is lacking. Despite the model's relevance to several conditions, including attention deficit hyperactivity disorder (ADHD), we are unaware of any studies that have examined the model in clinical populations.

METHODS

The current study used an eye-tracking Pavlovian conditioning paradigm to identify ST and GT in non-clinical (N = 54) and ADHD (N = 57) participants. Eye movements were recorded whilst performing the task. Dwell time was measured for two areas of interest: sign (i.e., cue) and goal (i.e., reward), and an eye-gaze index (EGI) was computed based on the dwell time sign-to-goal ratio. Higher EGI values indicate sign-tracking behaviour. ST and GT were determined using median and tertiary split approaches in both samples.

RESULTS

Despite greater propensity for sign-tracking in those with ADHD, there was no significant difference between groups. The oculomotor conditioned response was reward-specific (CS+) and present, at least partly, from the start of the task indicating dispositional and learned components. There were no differences in externalising behaviours between ST and GT for either sample.

CONCLUSIONS

Sign-tracking is associated with CS+ trials only. There may be both dispositional and learned components to sign-tracking, potentially more common in those with ADHD. This holds translational potential for understanding individual differences in reward-learning.

Exercise Dependency and Overuse Injuries in Attention Deficit Hyperactivity Disorder

ABSTRACT

Attention deficit hyperactivity disorder (ADHD) is a common condition, but current medications have limitations, pushing a drive for alternative approaches. Different exercise-focused approaches have shown promise, but concern has also been raised about individuals with ADHD showing greater risk of addiction, including exercise dependency. Using an online survey, we examined current exercise practices, including exercise dependency and the presence of overuse injury, which could result from overexercising, in 114 adults with ADHD. We found that most were regularly exercising. None were classified as exercise dependent, but 38.9% were deemed symptomatic nondependent. Hyperactive-impulsive symptoms were a predictor of the level of exercise withdrawal experienced, and the co-occurrence of autism spectrum disorder was associated with greater risk of overuse injuries. The data indicate that ADHD may confer some greater risk of exercise dependency, aligning with previous studies investigating other addictions and suggesting further research is critical.

Factors Influencing the Medication Adherence in Adults With Attention-Deficit/Hyperactivity Disorder (ADHD) and Its Impact on Healthcare Utilization

OBJECTIVE

This study aims to investigate the factors influencing medication adherence among adults with Attention-Deficit/Hyperactivity Disorder (ADHD) and impact of central nervous system stimulants (CNS) adherence on healthcare utilization (HCU). Methods: This was a cross-sectional study using Medical Expenditure Panel Survey 2013 to 2019, with participants (≥18 years of age) with ADHD and had at least one CNS prescription. Multivariate logistic and linear regression were utilized to evaluate the medication adherence and its impact on HCU, respectively.

RESULT

Total 798 (10,718,005 weighted) ADHD patients, were mostly White (81%), aged between 18 and 25 (35%), and non-adherent to CNS (65%). The use of extended-release medications (OR = 1.51 [1.03, 2.23]) and new users (OR = 3.46 [2.12, 5.63], p ≤ .05) were positively associated with medication adherence. The adherent group utilized more outpatient visits (0.04 vs. 0.46) and prescription refills (18.38 vs. 31.25) compared to non-adherent.

CONCLUSION

Our findings can be applied to improve the medication adherence, patient education, and optimize intervention for adults with ADHD.

The effects of tryptophan loading on Attention Deficit Hyperactivity in adults: A remote double blind randomised controlled trial

BACKGROUND

Despite the impact and prevalence of Attention Deficit Hyperactivity Disorder (ADHD), current treatment options remain limited and there is a drive for alternative approaches, including those building on evidence of a role for tryptophan (TRP) and serotonin (5-HT). This study aimed to evaluate the effect of acute TRP loading on attention and impulsivity in adults with ADHD.

TRIAL DESIGN AND METHODS

We conducted a remote double blind randomised controlled trial (RCT) using TRP loading to examine the effects of a balanced amino acid load in comparison to low and high TRP loading in individuals with ADHD (medicated, N = 48, and unmedicated, N = 46) and controls (N = 50). Participants were randomised into one of three TRP treatment groups using stratified randomisation considering participant group and gender using a 1:1:1 ratio. Baseline testing of attention and impulsivity using the Test of Variables of Attention Task, Delay Discounting Task, and Iowa Gambling Task was followed by consumption of a protein drink (BAL, LOW, or HIGH TRP) before repeated testing.

RESULTS AND CONCLUSIONS

No effects of TRP were observed for any of the measures. In the present study, TRP loading did not impact on any measure of attention or impulsivity in those with ADHD or Controls. The findings need to be confirmed in another trial with a larger number of patients that also considers additional measures of dietary protein, plasma TRP and aggression. (Registration ID ISRCTN15119603).

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.

Exploring the Relationship between Cardiorespiratory Fitness and Executive Functioning in Adults with ADHD

OBJECTIVE

Associations between measures of executive functioning (EF) and cardiorespiratory fitness (CRF) were examined for adults with and without ADHD.

METHOD

Measures of executive functioning including the Stroop task, Wisconsin Card Sorting task, and Operation Span Task were completed virtually (n = 36 ADHD; n = 36 Control). Participants completed the Six-Minute Walk Test to estimate CRF.

RESULTS

Mean performance measures of executive function did not differ by group. However, higher estimated CRF was associated with better Stroop task performance, and the association was strongest for individuals with ADHD.

CONCLUSION

In adults with ADHD, higher estimated CRF was associated with better inhibitory control, but not with other measures of executive functioning.

The Effects of Different Exercise Approaches on Attention Deficit Hyperactivity Disorder in Adults: A Randomised Controlled Trial

Attention deficit hyperactivity disorder (ADHD) results in significant functional impairment. Current treatments, particularly for adults, are limited. Previous research indicates that exercise may offer an alternative approach to managing ADHD, but research into different types of exercise and adult populations is limited. The aim of this study was to examine the effects of acute exercise (aerobic cycling vs mind-body yoga exercises) on symptoms of ADHD in adults. Adults with ADHD (N = 82) and controls (N = 77) were randomly allocated to 10 min of aerobic (cycling) or mind-body (Hatha yoga) exercise. Immediately before and after exercise, participants completed the Test of Variables of Attention task, Delay Discounting Task, and Iowa Gambling Task to measure attention and impulsivity. Actigraphy measured movement frequency and intensity. Both groups showed improved temporal impulsivity post-exercise, with cycling beneficial to all, whilst yoga only benefited those with ADHD. There were no effects of exercise on attention, cognitive or motor impulsivity, or movement in those with ADHD. Exercise reduced attention and increased movement in controls. Exercise can improve temporal impulsivity in adult ADHD but did not improve other symptoms and worsened some aspects of performance in controls. Exercise interventions should be further investigated.

A systematic review of interventions to enhance adherence and persistence with ADHD pharmacotherapy

Although high rates of poor adherence/persistence have been documented in ADHD, there is limited research targeting the problem. This systematic review evaluated interventions to address poor adherence/persistence to ADHD pharmacotherapy, with the aim of guiding the development of future interventions. An extensive search was conducted from January 1980 until January 2021. Thirteen studies were identified involving interventions based on psychoeducation, behavioural therapy, combined psychoeducation/behavioural therapy, technology-based interventions, written informed consent and a nursing support line. All 13 studies (including five RCTs) reported improvement in adherence/persistence and five studies (including four RCTs) also reported improvement in ADHD symptomatology. Almost all studies involved interventions utilising some form of education. Three RCTs of psychoeducation alone were included, with two of the three studies reporting adherence benefits at three and 12 months respectively. The third RCT was terminated early due to poor recruitment. A behavioural intervention RCT reported improved adherence six months post intervention (but not at 12 months), although a substantial drop-out rate was observed. A final included RCT used a Smartphone Application and reported a short term increase in adherence. The authors of the studies in this review make salient attempts at improving adherence and provide insight for future intervention development. We believe future interventions should involve combinations of strategies, have a theoretical framework and target the most common reasons for non-adherence. Interventions should also be integratable into routine care and include patient input to maximise sustainability.

The Association of Oral Stimulant Medication Adherence with Work Productivity among Adults with ADHD

OBJECTIVE

Examine associations between oral psychostimulant pharmacotherapy adherence, work productivity, and related indirect costs among US adults with ADHD.

METHODS

Medication adherence (Medication Adherence Reasons Scale [MAR-Scale]), work productivity and activity impairment (Work Productivity and Activity Impairment-General Health questionnaire), and ADHD symptom level (Adult ADHD Self-Report Scale version 1.1 Symptom Checklist) were assessed in this noninterventional online survey of adults who self-reported having an ADHD diagnosis and were currently receiving oral psychostimulant treatment for ≥3 months.

RESULTS

Of 602 respondents, 395 had low/medium adherence (LMA: MAR-Scale total score ≥1) and 207 had high adherence (HA: MAR-Scale total score 0). After adjusting for covariates, the LMA group had significantly greater levels of absenteeism, absenteeism-related indirect costs, and total indirect costs (all p < .01) than the HA group.

CONCLUSION

In adults with ADHD using oral psychostimulants, lower medication adherence was associated with greater absenteeism and indirect costs.

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).

ADHD, financial distress, and suicide in adulthood: A population study

Attention-deficit/hyperactivity disorder (ADHD) exerts lifelong impairment, including difficulty sustaining employment, poor credit, and suicide risk. To date, however, studies have assessed selected samples, often via self-report. Using mental health data from the entire Swedish population (N = 11.55 million) and a random sample of credit data (N = 189,267), we provide the first study of objective financial outcomes among adults with ADHD, including associations with suicide. Controlling for psychiatric comorbidities, substance use, education, and income, those with ADHD start adulthood with normal credit demand and default rates. However, in middle age, their default rates grow exponentially, yielding poor credit scores and diminished credit access despite high demand. Sympathomimetic prescriptions are unassociated with improved financial behaviors. Last, financial distress is associated with fourfold higher risk of suicide among those with ADHD. For men but not women with ADHD who suicide, outstanding debt increases in the 3 years prior. No such pattern exists for others who suicide.

An innovative SMS intervention to improve adherence to stimulants in children with ADHD: Preliminary findings

BACKGROUND

Although large datasets document that stimulants decrease the risk for many adverse ADHD-associated outcomes, compliance with stimulants remains poor.

AIMS

This study examined the effectiveness of a novel ADHD-centric text messaging-based intervention aimed to improve adherence to stimulant medications in children with ADHD.

METHODS

Subjects were 87 children aged 6-12, who were prescribed a stimulant medication for ADHD treatment. Prescribers gave permission to contact their patients for participation in the study. Subjects were primarily from the primary care setting with a subsample of psychiatrically referred subjects for comparison. Age- and sex-matched comparators were identified (3:1) from the same pool of prescriber-approved subjects that did not participate. Timely prescription refills (within 37 days) were determined from prescription dates documented in patients' electronic medical record.

RESULTS

Eighty-five percent of SMS intervention patients refilled their prescriptions in a timely manner compared with 62% of patients receiving treatment as usual (OR = 3.46, 95% CI: 1.82, 6.58; p < 0.001). The number needed to treat statistic was computed as five, meaning for every five patients who receive the SMS intervention, we can keep one adherent to their stimulant treatment.

CONCLUSIONS

These preliminary findings support the potential utility of a readily accessible technology to improve the poor rate of adherence to stimulant treatment in children with ADHD. To the best of our knowledge, this study is the first digital health intervention aimed at improving adherence to stimulant medication for children with ADHD. These results support the need for further examination of this technology through more definitive randomized clinical trials.

The Transition of Youth with ADHD into the Workforce: Review and Future Directions

Previous research suggests that a majority of children with attention-deficit/hyperactivity disorder (ADHD) continue to experience increased impairment across multiple life domains into adulthood. A systematic review of the occupational impairments, and associated educational and financial difficulties, faced by individuals with childhood ADHD was conducted. Systematic searches from PsycINFO and PubMed databases and other sources (i.e., books and consultants with experts) yielded 35 relevant articles that described 19 longitudinal studies on adults with a history of ADHD or related symptoms. Multiple studies indicated that those with a history of ADHD had more educational impairment and were less likely to graduate from high school and college than their peers without a history of ADHD. Subsequently, they faced lower occupational attainment, had more job instability, and demonstrated more impaired job performance, and these outcomes were largely consistent regardless of sex, medication history, or symptom persistence. Similar results were found in clinical and representative national studies in both U.S. and abroad, although older studies tended to indicate less occupational impairment. In addition, ADHD was associated with a number of financial challenges, including lower annual income, more reliance on public aid, and increased risk for homelessness. Future research should use more varied informant sources and utilize innovative measures of occupational impairment at both a macro- and micro-level of analyses. In addition, studies of effective supports and interventions in occupational settings for individuals with ADHD are needed.

Examining Breaks and Resistance in Medication Adherence Among Adolescents With ADHD as Associated With School Outcomes

Objective: Pharmacological interventions combined with behavioral treatment have been associated with better outcomes for children with ADHD. Yet, as children age into adolescence and gain autonomy, they may choose not to adhere to taking a prescribed medication. The purpose of the current study was to examine school outcomes among adolescents with ADHD who take medication breaks versus resisting medication with respect to grades and school behaviors. Method: We statistically controlled for a variety of variables such as the child's age, sex, the presence of side effects, and parent's relationship with child. Approximately half of the sample of adolescents with ADHD exhibited some form of medication nonadherence. Results: The results of the current study suggest that more positive school outcomes in terms of behaviors and grades are associated with adolescents taking breaks from their ADHD medication rather than resisting their medication. Conclusion: This result would indicate that not all forms of medication nonadherence have the same association with school outcomes in terms of grades and behaviors.

Treatment adherence and persistence in adult ADHD: Results from a twenty-four week controlled clinical trial with extended release methylphenidate

Purpose:

The aim of this analysis is to describe medication adherence, and treatment persistence, in adults with attention deficit/hyperactivity disorder (ADHD) treated for 24 weeks with extended release methylphenidate (MPH-ER). Additionally, patient-, disorder- and treatment-related factors associated with adherence and persistence will be identified.

Method:

Post-hoc analysis of the active treatment group of a placebo-controlled, randomised, 24 week trial with MPH-ER with univariate description and multiple logistic regression models and Hosmer and Lemeshow tests.

Results:

In the sample of 241 adults with ADHD (mean age of 35.2 ± 10.1 years), 9.4% of the patients were non-adherent, taking less than 80% of the dispensed medication. Factors associated with non-adherence included age < 25 years, education level lower than secondary education, lacking family history of ADHD, lower ADHD baseline severity and lower self- and observer-rated medication efficacy. Lacking family history of ADHD, lower education level and lower self-rated medication efficacy, predicted non-adherence with a prediction accuracy of 16%. Seventeen percent of the patients discontinued early with most discontinuing within the first five weeks of the MPH-ER titration phase. Mean persistence in the discontinuing group was 63.4 ± 49.4 days. Factors associated with discontinuation included male gender, lower education level, lacking family history of ADHD and lower self- and observer-rated medication efficacy. Treatment non-response, male gender and lower education level predicted treatment discontinuation with a prediction accuracy of 22.7%.

Conclusion:

Male adults without relatives with ADHD, with lower educational level and lower self- and observer-rated medication efficacy, who are newly treated with MPH-ER, are at increased risk of non-adherence and treatment discontinuation. Patients are at increased risk of treatment discontinuation during the medication titration phase.

Adherence to medication in adults with attention deficit hyperactivity disorder and pro re nata dosing of psychostimulants: A systematic review

Adherence to a regular medication regimen may be challenging for adults with attention deficit hyperactivity disorder (ADHD). Some report taking psychostimulants on a pro re nata (PRN) basis. This review aims to establish the rate of adherence, and reasons for and consequences of non-adherence to medication for ADHD in adults, and to review literature on PRN dosing of psychostimulants in these patients. A systematic literature search was conducted. Four primary research studies have investigated the rate of adherence to medication in adults with ADHD. Mean adherence rate in two studies ranged from 52% to 87%. A number of possible reasons for poor adherence have been suggested. Prospective studies are needed to further define the rate of adherence and causes of poor adherence. Evidence examining whether differences in adherence affect clinical outcomes is equivocal. Therefore, caution should be applied to the assumption that maximising adherence to regular medication regimens will improve clinical outcomes. Two articles acknowledge that patients take medication on a PRN basis. Studies comparing the effectiveness of a regular and PRN regimen of psychostimulants are needed. If PRN dosing is as effective as a regular regimen, advantages might include enhanced doctor-patient communication, reduced side effects and cost savings.

A Novel Text Message Intervention to Improve Adherence to Stimulants in Adults With Attention Deficit/Hyperactivity Disorder

BACKGROUND

Attention deficit/hyperactivity disorder (ADHD) is a prevalent neurobiological disorder associated with a wide range of adverse outcomes. Although large data sets document that stimulants decrease the risks for many ADHD-associated adverse outcomes, compliance with stimulants remains very poor. The main aim of this study was to assess the effectiveness of a novel text messaging-based intervention aimed at improving the poor rate of adherence to stimulant medications in adults with ADHD.

METHODS

Subjects were adults with ages 18 to 55, prescribed a stimulant medication for ADHD treatment. For comparators, we identified at a 5-to-1 ratio (age and sex matched) adult patients from the Partners HealthCare electronic medical record who had been prescribed stimulant medications over a 1-year period. We determined whether patients had timely prescription refills, defined as refilled within 37 days, using prescriptions documented in their electronic medical record.

RESULTS

Our results showed that 68% of the SMS intervention group refilled their prescriptions in a timely manner. In contrast, only 34% of patients receiving treatment as usual refilled their prescriptions in a timely fashion (odds ratio, 4.04; 95% confidence interval, 2.49-6.56; P < 0.001).

CONCLUSIONS

These data indicate that an innovative ADHD-centric text messaging intervention significantly improved patient engagement to treatment with stimulants in adults with ADHD. Findings provide strong support for the use of a readily accessible, inexpensive, and widely available technology to improve the poor rate of adherence to stimulant treatment in adults with ADHD. To the best of our knowledge, this study is the first digital health intervention aimed at improving adherence to stimulant medication for adults with ADHD.

Exploring factors influencing initiation, implementation and discontinuation of medications in adults with ADHD

Background

Adherence to ADHD medication is a complex phenomenon as the decision to adhere is influenced by a range of factors. To design tailored interventions to promote adherence, it is important to understand the factors that influence adherence in the context of its three phases: initiation, implementation and discontinuation.

Objective

The objective of this study was to explore the phase‐specific factors that influence adherence to medication in adults who have a diagnosis of ADHD.

Methods

Three focus groups (FGs) were conducted with twenty adults with ADHD in different metropolitan areas of Sydney, Australia. FGs were transcribed verbatim and thematically analysed.

Results

Participants’ decision to initiate medication (the initiation phase) was influenced by their perceived needs (desire to improve academic and social functioning) and concerns (fear of side‐effects) about medication following a similar process as defined by the Necessity‐Concerns Framework (NCF). The balance between benefits of medication (needs) and side‐effects (concerns) continued to determine participants’ daily medication‐taking (the implementation phase) and persistence (or discontinuation) with their medication. Forgetfulness and stigma were reported as concerns negatively impacting the implementation phase, while medication cost and dependence influenced the discontinuation phase of adherence.

Conclusions

Adults’ decision to initiate, continue or discontinue medication is influenced by a range of factors; some are unique to each phase while some are common across the phases. Participants balanced the needs for the medication against their concerns in determining whether to adhere to medication at each phase. It appears that the NCF has applicability when decision making about medication is explored at the three phases of adherence.

Barriers to Treatment Adherence Among College Students with Attention-Deficit/Hyperactivity Disorder

OBJECTIVE

The current study sought to obtain a longitudinal perspective of and quantitatively assess barriers to medication adherence experienced by college students with attention-deficit/hyperactivity disorder (ADHD). Thus, we examined semester-long trends in barriers to adherence in addition to the relationships between barriers and medication adherence and barriers and quality of life.

METHODS

Participants were college students diagnosed with ADHD. Throughout a Fall semester, participants completed 4 sets of online questionnaires and attended 4 in-person visits, which included pill counts and written questionnaires. Participants completed measures assessing barriers to adherence and health-related quality of life, and adherence was measured via pill counts. Mean values of barriers, adherence rate, and quality of life were used for all analyses.

RESULTS

Of the 45 students surveyed, mean adherence rate was 56.70%, and 84.45% of participants reported at least 1 barrier. Across the semester, participants reported experiencing an average of 3.07 barriers, and a consistent barrier reported was not realizing when pills run out. Although reported barriers were unrelated to adherence, the results showed that barriers were associated with lowered quality of life, specifically lower overall quality of life in addition to lower emotional functioning, psychosocial health, school functioning, and physical functioning.

CONCLUSION

Barriers to adherence appear to be common in college students with ADHD, and certain barriers are consistent with the planning difficulties observed in individuals with ADHD. Because students experiencing more barriers had lower quality of life, interventions are needed to improve students' overall illness management experience.

Pharmacokinetics of methylphenidate and ritalinic acid in plasma correlations with exhaled breath and oral fluid in healthy volunteers

PURPOSE

The primary aim of this study was to explore the potential of alternative sampling matrices for methylphenidate by assessing the correlations between dl-threo-methylphenidate and dl-threo-ritalinic acid concentrations in exhaled breath and oral fluid with those in plasma, in repeated samples collected after a single oral dose of methylphenidate. The secondary aim was to study the enantioselective pharmacokinetics of methylphenidate in plasma, with a focus on interindividual variability in the metabolism of methylphenidate to ritalinic acid.

METHODS

Twelve healthy volunteers received a single oral dose of dl-threo-methylphenidate (Ritalin® capsules, 20 mg). Venous blood samples were collected for 24 h, and plasma analyzed for threo-enantiomers of methylphenidate and ritalinic acid with LC-MS/MS. Repeated sampling of exhaled breath, using a particle filter device, and of non-stimulated oral fluid, using a felt pad device, was also performed. Exhaled breath and oral fluid were analyzed with a non-enantioselective LC-MS/MS method for dl-threo-methylphenidate and dl-threo-ritalinic acid.

RESULTS

In all subjects, d-threo-methylphenidate was detectable in plasma for at least 15 h after the dose with a biphasic profile. l-threo-Methylphenidate was measurable in only five subjects and in most cases in low concentrations. However, one female subject displayed a biphasic concentration-time profile for l-threo-methylphenidate. This subject also had the highest d-threo-methylphenidate AUC (191 ng*h/mL versus 32-119 ng*h/mL in the other subjects). d-threo-Ritalinic acid concentrations were on average 25-fold higher (range 6-126) than the corresponding d-threo-methylphenidate concentrations. Single-time point plasma concentration ratios between d-threo-ritalinic acid and d-threo-methylphenidate 1.5-12 h after dose correlated highly (r = 0.88-0.98) with the d-threo-ritalinic acid AUC/d-threo-methylphenidate AUC ratio. In eleven subjects, dl-threo-methylphenidate in oral fluid mirrored the biphasic profile of methylphenidate (sum of d- and l-threo-enantiomers) in plasma, but the concentrations in oral fluid were on average 1.8 times higher than in plasma. dl-threo-Methylphenidate was detected in exhaled breath in all subjects, but there was no consistent concentration-time pattern.

CONCLUSIONS

In some subjects, the pharmacologically less active l-threo-enantiomer may contribute to the total plasma methylphenidate concentrations. Monitoring methylphenidate concentrations without enantiomeric determination carries the risk of missing such subjects, which might affect how the plasma concentrations of methylphenidate are interpreted and used for clinical decision making. The use of exhaled breath and oral fluid to assess medication adherence to MPH in patients with ADHD warrants further studies.

A Review of Factors Influencing the Three Phases of Medication Adherence in People with Attention-Deficit/Hyperactivity Disorder

Objectives: Factors affecting adherence to medications in people with attention-deficit/hyperactivity disorder (ADHD) are not well understood in the context of their influence on the different phases of adherence, that is, initiation, implementation, and discontinuation. This review aimed to identify the factors affecting the three phases of medication adherence in people with ADHD. Methods: Six electronic databases, including Medline, PubMed, IPA, CINAHL, Embase, and PsycINFO, were systematically searched from inception through October 2018 with the limitations of English language and human studies. The search strategy was based on three concepts (adherence, ADHD, and factors) and their relevant terminologies. Results: Considerable variability was observed with regards to the criteria used to define adherence in identified studies (n = 48). Most studies focused on the implementation phase of adherence (n = 27), while only a handful focused on the initiation (n = 6) and discontinuation (n = 5) phase of adherence. The remaining studies (n = 10) examined multiple phases of adherence. Conflicting information received about medication, medication frequency, and fears of medication's effect on growth were the unique factors impacting initiation, implementation, and discontinuation, respectively. Moreover, factors within each phase of adherence also differed with different populations such as parents, children, adolescents, and adults. Fear of addiction, medication effectiveness, psychiatric comorbidity, and medication side effects were the most common factors identified in all three phases of adherence. Conclusions: This review found some unique factors in each phase of adherence while some overlap was also noted. Future interventions to improve adherence should be phase- and group specific rather than consider adherence as a single variable.

Self-Management of Adherence to Prescribed Stimulants in College Students With ADD/ADHD

OBJECTIVE

We examined how college students manage ADHD medication and how beliefs regarding the medication and attitudes of friends and families influence adherence on weekdays and weekends during an academic semester.

METHOD

Undergraduate students ( n = 53) responded to an online survey to report their adherence, their beliefs about the effects of the medication, and their perception of important others' views of adherence.

RESULTS

Students chose to take more medication on weekdays than weekends. On weekdays, beliefs that the medications enhance academic performance and social skills influenced adherence, and on weekends, beliefs regarding negative side effects were important. The perception that medication leads to a loss of authentic self reduced adherence at both times. Generally, students believed that important others wanted them to take medication.

CONCLUSION

Students were actively weighing the costs and benefits of taking their ADHD medication and consciously adjusting adherence levels from day to day.

Persistence and Adherence to Psychostimulants, and Psychological Well-Being Up to 3 Years After Specialized Treatment of Adult Attention-Deficit/Hyperactivity Disorder: A Naturalistic Follow-Up Study

BACKGROUND

Little is known about the long-term persistence and adherence of psychostimulant use in adults with attention-deficit/hyperactivity disorder (ADHD) and its relationship to their psychological well-being.

METHODS

The persistence and adherence to psychostimulants and psychological well-being were examined in adults with ADHD in a naturalistic follow-up, starting directly after discharge from their specialized treatment of ADHD at an outpatient ADHD clinic. Ninety-six patients were included at the time of discharge, who were interviewed by telephone at 6 months, 1 year, and 3 years after discharge.

RESULTS

At the time of discharge, 78% used a psychostimulant prescribed by a psychiatrist. Of those on psychostimulants at the time of discharge, approximately half still used any of these psychostimulants 3 years after discharge. However, adherence rates were good for those who persisted to use psychostimulants. The female sex and middle educational level (relative to a higher educational level) were near-significantly related to nonpersistence, and having a higher educational level and the combined ADHD subtype were related to nonadherence. In turn, nonadherence was related to worse general functioning, lower mood, and poorer sleep quality.

CONCLUSIONS

The importance of adherence should be discussed at the time of discharge, especially with female ADHD patients, those with a higher educational level, and those with a combined ADHD subtype, because nonadherence is associated with poorer outcomes.

Adherence to Attention-Deficit/Hyperactivity Disorder Medication During the Transition to College

PURPOSE

The present study explores the medication self-management experiences of adolescents with attention-deficit/hyperactivity disorder (ADHD) during their transition to young adulthood in college.

METHODS

Participants were college freshmen with ADHD prescribed daily medication for their condition. Ten individual interviews were conducted using a semistructured interview script. Measures related to ADHD medication management were also completed. Qualitative data were analyzed via directed content analysis and quantitative data via descriptive statistics.

RESULTS

Five themes emerged from interviews: (1) transitions to independence are often abrupt, and many adolescents lack critical self-management skills; (2) volitional nonadherence is high due to inaccurate disease beliefs, perceived academic demands, and medication side effects; (3) poor self-management negatively impacts school performance; (4) peer pressure to share medication affects social functioning and adherence; and (5) social support is greatly needed. Common barriers to adherence included "don't feel like taking medication" (90%) and "difficulties in sticking to a fixed medication schedule" (80%).

CONCLUSIONS

Participants with ADHD were not prepared to manage their chronic illness independently in context of increased demands and newfound freedom, resulting in negative academic consequences. Social factors also play an influential role in ADHD self-management, particularly related to the isolation associated with sharing the medication and its side effects. Intervention programs targeting medication self-management during the transition to independence are greatly needed for young adults with ADHD as high academic performance in college is critical for future success.

Financial Dependence of Young Adults with Childhood ADHD

This study used data from the Pittsburgh ADHD Longitudinal Study (PALS) to evaluate financial outcomes of young adults (YA) with ADHD relative to comparisons. Participants for this study included 309 individuals who had been diagnosed with ADHD (DSM-III-R or DSM-IV) in childhood and 208 comparison YA without childhood ADHD diagnoses (total N = 517) who were followed through age 25. Participants were predominately male (88 %) and Caucasian (84 %). Diagnostic interviews were conducted in childhood. Young adults and their parents reported on financial outcomes and a number of predictor variables. Young adults with ADHD experienced greater financial dependence on family members (p < 0.05) and the welfare system (p < 0.01) and had lower earnings (p < 0.05) than comparisons. ADHD diagnostic status, education attainment, and delinquency were significant predictors of financial outcomes. A projection of lifetime earnings indicated that ADHD group participants could expect to earn $543,000-$616,000 less over their lifetimes than comparisons. Due to the propensity of individuals with ADHD to underreport problems, the data are likely to be underestimates. These findings support the need for interventions to improve labor market outcomes as well as the development of interventions that target the management of personal finances for individuals with ADHD in young adulthood.

Treatment outcomes after methylphenidate in adults with attention-deficit/hyperactivity disorder treated with lisdexamfetamine dimesylate or atomoxetine

PURPOSE

To compare treatment adherence, discontinuation, add-on, and daily average consumption (DACON) among adults with attention-deficit/hyperactivity disorder receiving second-line lisdexamfetamine dimesylate (LDX) or atomoxetine (ATX), following methylphenidate.

PATIENTS AND METHODS

A retrospective cohort study using US commercial claims databases (Q2/2009-Q3/2013).

RESULTS

At month 12, the LDX cohort (N=2,718) had a higher adherence level (proportion of days covered: 0.48 versus 0.30, P<0.001) and was less likely to discontinue (Kaplan-Meier estimate: 63% versus 85%, P<0.001) than the ATX cohort (N=674). There were no statistical differences in treatment add-on rates between cohorts (Kaplan-Meier estimate: 26% versus 25%, P=0.297). The LDX cohort had a lower DACON (1.10 versus 1.31, P<0.001) and was less likely to have a DACON >1 (adjusted odds ratio: 0.20, 95% confidence interval: 0.15-0.25, P<0.001) than the ATX cohort.

CONCLUSION

Adults with attention-deficit/hyperactivity disorder treated with LDX following methylphenidate had a higher treatment adherence and lower discontinuation and DACON relative to those treated with ATX following methylphenidate.

Quantifying the relationship between perceived consequences of ADHD medication and its usage

OBJECTIVE

To address a major barrier of medication noncompliance for individuals with ADHD, the authors present the ADHD Medication Attitude Scale (AMAS) with initial psychometric analyses and discriminant validity data.

METHOD

The AMAS was posted on ADHD websites, along with questions about demographics and medication usage over a 6-month period. A total of 356 ADHD respondents qualified for data analysis (160 males, 196 females, mean age = 18.58, years range = 13-62 years, SD = 6.07).

RESULTS

Factor analysis revealed two factors: one indicating positive and the other indicating negative attitude toward medication. The final refined 22-item scale demonstrated good reliability (α =.83). More positive and less negative attitude factor scores, as well as age (older than 19 years), independently predicted respondents' self-report of taking medication, χ(2) (1, N = 248) = 38.95, p < .001.

CONCLUSION

The AMAS is a psychometrically sound means of assessing attitudes toward ADHD medication, which significantly relate to self-reported medication usage.

Adherence to stimulants in adult ADHD

Although stimulant medication can reduce symptoms and lessen the degree of functional impairment associated with attention deficit hyperactivity disorder (ADHD), the adherence rate in adults diagnosed with ADHD is reportedly <12 %. The article explores the contexts that influence stimulant medication adherence in adults diagnosed with ADHD. Using a mixed-method design, data on ADHD-related quality of life and stimulant adherence were collected from 67 adults with ADHD. Next, 18 of those adults, based on adherence/quality of life, completed semi-structured interviews. Qualitative data were analyzed using thematic narrative inquiry, based on the Health Belief Model. Findings revealed no direct relation between stimulant adherence and quality of life. Instead, the doctor/patient relationship was a strong predictor of a person's quality of life. Physicians treating adults with ADHD must be aware of individual variation in stimulant response, seek to understand the functional limitations of their patients and strive to communicate effectively.

Pharmacological interventions for ADHD: how do adolescent and adult patient beliefs and attitudes impact treatment adherence?

Adherence to medication can be problematic for patients, especially so for patients with attention deficit hyperactivity disorder (ADHD). Effective medications are available for the treatment of ADHD; however, nonadherence rates for ADHD medication range from 13.2%-64%. The reasons for nonadherence can be complex. This review aims to look at how the beliefs and attitudes of adolescents and adults impact ADHD treatment adherence.

Attention-deficit/hyperactivity disorder in a chronic care paradigm

The prevalence and disease burden of adult attention-deficit/hyperactivity disorder (ADHD) suggests that primary care physicians (PCPs) have an opportunity to improve the functioning and quality of life of a significant number of adult patients. The American Academy of Pediatrics provides evidence-based clinical practice guidelines that recognize ADHD as a chronic condition, and a large proportion of children with ADHD continue to meet diagnostic criteria as adults. Therefore, the management of ADHD should incorporate principles common to the management of other chronic conditions, including proactive planning for continuity of treatment across the life span and integrated, multidisciplinary health care teams for optimal disease management. This article describes a clinical approach whereby adult ADHD is treated within a chronic care paradigm that prominently features the involvement of the PCP. If PCPs envision ADHD as a chronic illness, similar to asthma or diabetes, they may be less likely to refer individuals to be managed by specialists, and more likely to see their role in coordinating and monitoring adult ADHD care, knowing when and how to bring other resources into play, and when and how to educate patients.

Self-reported symptoms of adult attention deficit hyperactivity disorder among obese patients seeking bariatric surgery and its relation to alcohol consumption, disordered eating and gender

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT

Symptoms of adult attention deficit hyperactivity disorder (ADHD) are common among people with obesity. Symptoms of ADHD are associated with other impulsive behaviours. Impulsivity can manifest differently in women and men.

WHAT THIS STUDY ADDS

The prevalence of ADHD symptoms was equal in both sexes in this patient group. ADHD symptoms were associated with hazardous alcohol consumption in men but not in women. It may be important to investigate several comorbid conditions simultaneously instead of a single diagnosis. Eating disorders and adult attention deficit hyperactivity disorder (ADHD), both characterized by deficits in impulse control, are common among bariatric surgery patients. Previous studies in other groups have found gender differences in how symptoms of ADHD and eating disorders manifest as women show more disordered eating and men show more risk consumption of alcohol. In the present study, the association between symptoms of adult ADHD, eating disorders and hazardous alcohol consumption was investigated, while considering gender differences. Self-report questionnaires were obtained from 276 bariatric surgery patients 3-6 months before surgery. The prevalence rates of adult ADHD and binge eating disorder (BED) were 8.6% and 6.3%, respectively, with no evidence of gender difference in the prevalence rates. Hazardous alcohol consumption was reported by a significantly larger portion of men (16.9%) than women (8.6%). There was an association between adult ADHD and both BED and hazardous alcohol consumption. However, symptoms of adult ADHD were associated with hazardous alcohol consumption in men but not in women. Our results suggest gender differences in hazardous alcohol consumption and self-reported symptoms of disordered eating despite similar prevalence rate of BED, but no gender difference in symptoms of adult ADHD. Finally, as the associations between these variables seem to be different in women and men, future studies need to investigate potential gender-specific functional and temporal relations between these variables.

Psychosocial therapy in the treatment of adults with attention-deficit/hyperactivity disorder

Optimal management of attention-deficit/hyperactivity disorder (ADHD) requires a comprehensive treatment approach that reduces symptoms and improves quality of life. Psychosocial therapy, an important adjunct to pharmacotherapy for patients with ADHD, enables patients to improve functional performance across domains of life and maximizes the benefits of symptom reduction achieved via medication. This article evaluates the main types of psychosocial therapies used in the treatment of adult ADHD and discusses treatment goals within the context of skill acquisition and strength optimization. Factors influencing the success of psychosocial therapy and the role of a comprehensive treatment approach are also examined. The sequenced presentation of symptom reduction and skill acquisition plays a key role in coordinating psychosocial therapy and pharmacotherapy in a multimodal strategy for the effective treatment of adult ADHD.

ADHD medication vacations and parent-child interactions by gender

OBJECTIVE

The purpose of the current study was to examine medication vacations among children with ADHD according to parent-child dyads (e.g., mother-son, father-daughter, mother-daughter, and father-son).

METHOD

In a survey study of 259 parents of children with ADHD, the use of medication vacations according to parent-child sex dyads was examined.

RESULTS

Results of the current study suggest that fathers seem to report endorsing medication vacations more with their sons with ADHD as opposed to their daughters with ADHD. There did not seem to be any significant differences among mothers.

CONCLUSION

Results of the current study conclude with directions for future research and practice.

Comparing treatment adherence of lisdexamfetamine and other medications for the treatment of attention deficit/hyperactivity disorder: a retrospective analysis

OBJECTIVE

To assess treatment adherence in attention deficit/hyperactivity disorder (ADHD) patients initiated on Lisdexamfetamine (LDX) vs other FDA-approved stimulants and non-stimulant medications.

METHODS

ADHD patients initiated on an ADHD medication (index medication) were selected from a large US administrative claims database. Based on age and previous treatment status, patients were classified into treatment-naïve children and adolescents (6-17 years old), previously treated children and adolescents, treatment-naïve adults (over 18 years old), and previously treated adults. Furthermore, based on their index medication, patients were classified into seven mutually exclusive treatment groups: LDX, atomoxetine (ATX), osmotic release methylphenidate hydrochloride long acting (OROS MPH), other methylphenidate/dexmethylphenidate long acting (MPH LA) and short acting (MPH SA), and amphetamine/dextroamphetamine short acting (AMPH SA) and long acting (AMPH LA). Treatment adherence (proportion of days covered by the index medication ≥0.8) over a 12-month period was compared across treatment groups using multivariate logistic regression models.

RESULTS

In children and adolescents, LDX patients were more likely to be adherent compared to patients in each of the other treatment groups, except in treatment-naïve patients where LDX patients had a similar likelihood (p = 0.6925) and were less likely (p = 0.0004) to be adherent compared to ATX and OROS MPH patients, respectively. In adults, the LDX treatment group was also more likely to be adherent compared to each of the other treatment groups, except compared to AMPH LA, where statistically insignificant differences were observed (previously treated: p = 0.6471, treatment-naïve: p = 0.0733).

LIMITATIONS

ADHD severity information was not available in the database. Accordingly, this study did not control for ADHD severity.

CONCLUSION

Overall, LDX-treated patients demonstrated a better treatment adherence compared to patients initiated on other ADHD medications, except for AMPH LA in adult and OROS MPH and ATX in treatment-naïve children and adolescents.

Predictors and impact of non-adherence in adults with attention-deficit/hyperactivity disorder receiving OROS methylphenidate: results from a randomized, placebo-controlled trial

BACKGROUND

Medication non-adherence has an important impact on treatment efficacy and healthcare burden across a range of conditions and therapeutic areas. The aim of this analysis was to determine predictors of non-adherence and impact of non-adherence on treatment response in adults with attention-deficit/hyperactivity disorder (ADHD).

METHODS

Post-hoc analysis of a 13-week randomized, double-blind placebo-controlled study of OROS methylphenidate (MPH) 54 and 72 mg/day. Primary efficacy variable was the Conners' Adult ADHD Rating Scale - Screening Version (CAARS:O-SV). Daily adherence was calculated as average daily adherence (100 × capsules taken/2), with overall adherence calculated as the average daily adherence. Predictors of adherence were assessed using mixed-effects logistic regression. Descriptive statistics were generated for change in CAARS:O-SV score for adherent (> 95% adherence) and non-adherent subjects. Predictors of change were analyzed using a mixed model.

RESULTS

Subjects were allocated to OROS MPH (54 mg, n = 87; 72 mg, n = 92) or placebo (n = 97). Mean adherence was 92.6% and 93.3% (OROS MPH 54 and 72 mg/day, respectively), versus 97.5% (placebo). Adherence was higher and less variable in completers. Factors significantly associated with non-adherence included female sex, shorter time since ADHD diagnosis, higher education level (completion of university) and score on the Drug Use Screening Inventory psychiatric disorders subscale. Improvements from baseline in CAARS:O-SV score were numerically greater in subjects defined as adherent than in those who were non-adherent. Significant predictors of CAARS:O-SV change in patients who completed the study included percentage adherence up to the point of assessment (p < 0.0001), baseline score (p < 0.0001) and family history of ADHD (p = 0.0003).

CONCLUSION

The results of this analysis suggest that newly diagnosed patients, those with a high score on the DUSI-R psychiatric disorder scale, women, and subjects with high educational degrees may be at increased risk of non-adherence. Clinicians and policymakers should therefore pay special attention to these individuals, as non-adherence is a significant predictor of reduced response to treatment.

TRIAL REGISTRATION

EudraCT #: 2007-002111-82.

Methamphetamine use and neuropsychiatric factors are associated with antiretroviral non-adherence

The present study assesses the impact of methamphetamine (METH) on antiretroviral therapy (ART) adherence among HIV+ persons, as well as examines the contribution of neurocognitive impairment and other neuropsychiatric factors [i.e., major depressive disorder (MDD), antisocial personality disorder (ASPD), and attention deficit disorder (ADHD)] for ART non-adherence. We examined HIV+ persons with DSM-IV-diagnosed lifetime history of METH abuse/dependence (HIV+ /METH+ ; n=67) as compared to HIV+ participants with no history of METH abuse/dependence (HIV+ /METH - ; n=50). Ancillary analyses compared these groups with a small group of HIV+ /METH+ persons with current METH abuse/dependence (HIV+ /CU METH+ ; n=8). Non-adherence was defined as self-report of any skipped ART dose in the last four days. Neurocognitive functioning was assessed with a comprehensive battery, covering seven neuropsychological domains. Lifetime METH diagnosis was associated with higher rates of detectable levels of plasma and CSF HIV RNA. When combing groups (i.e., METH+ and METH- participants), univariate analyses indicated co-occurring ADHD, ASPD, and MDD predicted ART non-adherence (p's < 0.10; not lifetime METH status or neurocognitive impairment). A significant multivariable model including these variables indicated that only MDD uniquely predicted ART non-adherence after controlling for the other variables (p<0.05). Ancillary analyses indicated that current METH users (use within 30 days) were significantly less adherent (50% prevalence of non-adherence) than lifetime METH+ users and HIV+ /METH- participants and that neurocognitive impairment was associated with non-adherence (p's < 0.05). METH use disorders are associated with worse HIV disease outcomes and ART medication non-adherence. Interventions often target substance use behaviors alone to enhance antiretroviral treatment outcomes; however, in addition to targeting substance use behaviors, interventions to improve ART adherence may also need to address coexisting neuropsychiatric factors and cognitive impairment to improve ART medication taking.

Naturalistic exploration of the effect of osmotic release oral system-methylphenidate on remission rate and functional improvement in Taiwanese children with attention-deficit-hyperactivity disorder

AIM

To determine the differences in the remission rate, recovery rate, functional improvement, and treatment adherence related to treatment with short-acting immediate-release methylphenidate (IR-MPH) and long-acting osmotic-release oral system-methylphenidate (OROS-MPH) in a naturalistic setting among Taiwanese children with attention-deficit-hyperactivity disorder (ADHD).

METHODS

A total of 757 children with ADHD, aged 6-18 years, was evaluated using the following in order determine functional improvement and treatment adherence: the Chinese version of the Swanson, Nolan, and Pelham, version IV scale (SNAP-IV-C), Clinical Global Impression-ADHD-Severity (CGI-S) to measure remission and recovery rates, the Chinese version of the Social Adjustment Inventory for Children and Adolescents (CSAICA), and caregiver's satisfaction rate, treatment adherence, and frequency of adverse effects.

RESULTS

According to the SNAP-IV-C scores, the remission rate was 30.72%, and the recovery rate was 16.38%. Compared to short-acting IR-MPH, OROS-MPH was associated with greater functional improvement and treatment adherence among children with ADHD.

CONCLUSION

OROS-MPH treatment at the adequate dosage can achieve higher remission and recovery rates, produce greater functional improvement, and result in better treatment adherence than IR-MPH treatment.

Medication adherence and symptom reduction in adults treated with mixed amphetamine salts in a randomized crossover study

OBJECTIVES

The study objectives were to 1) evaluate medication adherence for adults with attention-deficit/hyperactivity disorder (ADHD) treated with 3 times daily (TID) mixed amphetamine salts immediate release (MAS IR) versus once-daily (qAM) MAS extended release (MAS XR) in a randomized, crossover study; and 2) to examine the associations between adherence and efficacy for MAS IR and MAS XR.

METHODS

Sixty-two adults with ADHD were enrolled and 49 completed the study. The treatment condition order (TID-qAM or qAM-TID) was counterbalanced across participants, with an intervening washout period of ≥ 7 days. Adherence was assessed via 3 measures: 1) self-report, 2) pill count, and 3) the Medication Event Monitoring System (MEMS(®)). The primary efficacy measure was the ADHD Rating Scale (ADHD-RS); secondary measures included the Time-Sensitive ADHD Symptom Scale (TASS) and Clinical Global Impressions-Severity of Illness (CGI-S) scale.

RESULTS

Adherence to treatment as measured by self-report and pill count was not significantly different between MAS XR and MAS IR. Adherence was significantly better for MAS XR than MAS IR for all of the MEMS(®) measures. The mean change in ADHD-RS, TASS, and CGI-S scores at endpoint was significantly improved for both MAS IR and MAS XR and did not differ significantly between groups. There was not a significant adherence by efficacy interaction.

CONCLUSION

Adults with ADHD adhered equally well with MAS IR as with MAS XR when assessed by pill count and self-report, but not by the MEMS(®) measures. Both treatments significantly reduced ADHD symptoms, and efficacy was not significantly different between groups. Adherence was not associated with treatment outcome.

Relationship between medication use and cardiovascular disease health outcomes in the Jackson Heart Study

Even though some medications have the potential to slow the progress of atherosclerosis and development of CVD, there are many at-risk individuals who continue to resist the benefits that are available by not following the advice of medical professionals. Non-adherence to prescribed drug regimens is a pervasive medical problem that negatively affects treatment outcomes. Information from standardized interviews of 5301 African Americans participating in the Jackson Heart Study was examined to determine the association between demographic parameters, behavior including adherence to prescribed medical regimens, and health outcomes. Data were also collected at Annual Follow-Up and Surveillance visits. During the two weeks prior to the examination visit, almost 52% of the participants reported taking blood pressure medication, 14% took cholesterol medication, 16% took medication for diabetes, and 19% took blood thinning medication. Of those who did not take the prescribed medications, the reasons given were the following: 47% were in a hurry, too busy, or forgot to take medications; 23% were trying to do without medications; 18% had no money to purchase medications; 19% indicated that the medications made them feel bad; 17% felt that they could not carry out daily functions when taking medications. The African American population can benefit from heightened awareness of the risk factors that are associated with CVD and the benefits of following a prescribed treatment regimen. Unacceptable secondary effects of prescribed medication comprised an important cause of non-compliance. Encouragement of this population to communicate with their healthcare providers to ensure that medication regimens are better tolerated could increase compliance and improve health outcomes.

Child and caregiver issues in the treatment of attention deficit–hyperactivity disorder: education, adherence and treatment choice

There is much more to successful drug treatment than writing a prescription. In this article, we describe some of the ‘holistic’ aspects of the pharmacological treatment of attention deficit–hyperactivity disorder, with an emphasis on helping families to decide between psychological and pharmacological treatment and on the process of psychoeducation. Detailed accounts of drug and behavioral treatment in various circumstances are available elsewhere; however, the value and process of psychoeducation is sometimes underestimated or referred to in a cursory statement of the need for a good doctor–patient relationship. There has been little in the way of controlled trials, so no meta-analysis is attempted. Where possible (e.g., in reviewing the effects of psychological therapy and prediction of drug response), PubMed/Medline was searched for systematic reviews and randomized trials, but this article’s conclusions should be taken as personal. These subjective views are based chiefly on experience in clinical practice, participation in focus groups with young people and their families and work with support groups.