Prevalence of comorbid substance use disorder during long-term central stimulant treatment in adult ADHD

Department of Neuroscience, Norwegian University of Science and Technology, Trondheim, Norway, .
ADHD Attention Deficit and Hyperactivity Disorders 10/2012; 5(1). DOI: 10.1007/s12402-012-0094-2
Source: PubMed


Central stimulant (CS) therapy is a cornerstone in treatment of adult attention-deficit/hyperactivity disorder (ADHD). Substance use disorder (SUD) is a common comorbid disorder of ADHD and might complicate the treatment. Our main objectives were to investigate the prevalence of SUD during CS treatment, and identify variables associated with SUD during the treatment. The collection of data was based on a naturalistic, retrospective approach using the medical records of a cohort of all adult ADHD patients (N = 117) starting treatment with CS in a specific catchment area in the period 1997 to May 2005. A logistic regression model was applied to identify possible predictors of SUD during CS treatment. The study showed no onset of SUD during the CS treatment in the group of patients without comorbid SUD at baseline (mean CS treatment length 41.1 months). In the group of patients with comorbid SUD at baseline, 58.5 % had one or more relapses of SUD during treatment (mean CS treatment length 27.9 months). Younger age and comorbid antisocial personality disorder were associated with relapse. In a logistic regression analysis, cannabis abstinence for more than 12 months was a negative predictor for relapse of SUD. CS treatment does not precipitate onset of SUD in adults without previous SUD.

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    ABSTRACT: This study investigated the agreement on treatment for attention-deficit/hyperactivity disorder (ADHD) between adults with ADHD and the primary care physicians responsible for their treatment. Adults with ADHD and the primary care physicians responsible for their ADHD treatment completed a survey. The κ-statistic assessed physician-patient agreement on ADHD treatment variables. The eligible sample consisted of 274 patients with confirmed current or previous psychopharmacological treatment for ADHD and the physicians responsible for their treatment. We received 159 questionnaires (58.0 %) with sufficient information from both sources. There were no significant differences between participants and nonparticipants (N = 115) on ADHD sample characteristics. Participants' mean age was 37.6 years, and 75 (47.2 %) were females. There was high agreement for current pharmacological treatment for ADHD, current and last ADHD drug prescription, treatment for substance use, and misuse of stimulant medication. Agreement for nonpharmacological treatment for ADHD and treatment termination because of the side effects was low. A minority of participants from both sources reported misuse of stimulant medication. There was a moderate correlation between the physicians' clinical judgment and patients' self-report on current functioning. The study showed that primary care physicians and their patients agreed on the pharmacological but not the nonpharmacological, treatments given. They also agreed on patients' current functioning. Physicians and patients reported low levels of misuse of stimulant medication. The results show that pharmacological treatment for adults with ADHD can be safely undertaken by primary care physicians.
    ADHD Attention Deficit and Hyperactivity Disorders 08/2013; 5(4). DOI:10.1007/s12402-013-0116-8
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    ABSTRACT: There is a lack of long-term studies of central stimulant (CS) treatment in adult attention-deficit/hyperactivity disorder (ADHD), and studies on functional outcomes like occupational status are rare. The current study investigated occupational status in adult ADHD patients before and after long-term CS treatment (median duration of treatment 33 months) and aimed to identify variables associated with improvement in occupational status. The collection of data was based on a naturalistic, retrospective approach using the medical records of a sample of all 117 adult ADHD patients consecutively starting treatment with CS in a specific catchment area in Norway in the period 1997 to May 2005. Most patients did not improve in occupational status during long-term CS treatment. The improved group had significantly higher baseline ADHD symptoms as measured by the general adult ADD symptom checklist (83.7 vs. 76.2, p = 0.024) and had a significantly shorter period from the first contact with adult psychiatry until they got the ADHD diagnosis (11.7 vs. 50.9 months, p = 0.001). The results indicate that long-term CS treatment itself may have limited effect on occupational status in functionally impaired and highly comorbid patients with adult ADHD. A high baseline ADHD symptom level may be related to a superior outcome in occupational status.
    ADHD Attention Deficit and Hyperactivity Disorders 04/2014; 6(4). DOI:10.1007/s12402-014-0135-0
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    ABSTRACT: Background: ADHD in adulthood is associated with a wide range of clinical and psychosocial impairments, and the number of adults referred for medical treatment is considerable. Aims: The overall purpose of this thesis was to study clinically relevant aspects of long-term medical treatment of patients with adult ADHD. To achieve this, three aims were defined: 1) To systematically review the literature on long-term (= 24 weeks) pharmacological treatment of adults with ADHD (Study I); 2) To explore educational and occupational status as functional outcomes in previously not medicated adult ADHD patient (Study II); and 3) To assess outcomes of a 12 months first time medical treatment period of such patients (Study III). Materials and methods: In Study I we reviewed electronic databases to identify original studies of long-term effects of stimulant therapy in adults. Studies II and III were conducted on a sample of patients recruited at a specialized outpatient clinic for adult ADHD patients. Study II was a cross-sectional investigation of the impact of retrospectively retrieved childhood dimensional ADHD symptoms and characteristics as well as present state ADHD symptoms on the current level of basic education and current work status in medication-naïve adults with ADHD. Study III was an open-labeled prospective observational study of the 250 adults consecutively included and described in Study II, who received methylphenidate according to current guidelines with a titration-regime for 6 weeks, followed by a flexible-dose-regime. Patients, who did not respond or were non-tolerant for methylphenidate, were shifted to amphetamine or atomoxetine. Results: Study I: Most of published pharmacological studies reviewed were short-term randomized placebo-controlled trials (RCTs); four trials had intermediate duration between 24 weeks and one year. In contrast to findings in the short- and intermediate term (< 24 weeks) trials, where drug effects are well established, long-term effects (> 24 weeks) of medication on symptoms and functional outcomes, as well as side effects or complications, were less studied. We identified some open label extension studies from short term RCTs (n = 10) that evaluated outcome up to 52 weeks, except for one study on atomoxetine of three years. Study II: High number of childhood hyperactive-impulsive symptoms and overall severity of childhood ADHD-symptoms were significantly associated with high drop-out rates from school (OR = 3.0), while persisting ADHD inattentive symptoms (OR = 2.5) and comorbid mental disorders (OR = 1.6) in adulthood were more related to the proportion with long-term work disability. Study III: A total of 232 patients (93%) starting medical treatment completed examination at 12-months, and 70% of them persisted on medication, most commonly methylphenidate, while 30% had discontinued medication. Longitudinal analyses showed significant associations between sustained improvement of symptoms and global functioning measures, and staying on medication. Comorbid mental disorders and adverse effects of medication were related to both lower effectiveness, and reduced adherence to treatment. No serious adverse events were observed. Conclusions: Study I: The literature on long-term effects of ADHD-medication in adults was scarce and primarily naturalistic. The results suggested that pharmacological treatment of ADHD leads to less symptoms, better self-esteem, higher educational levels and occupational status, fewer accidents, and less delinquency compared to non-treatment, and medication was well tolerated. Study II: Higher levels of untreated childhood ADHD hyperactive-impulsive symptoms and overall severity of ADHD symptoms were associated with lower level of basic education. Persisting ADHD inattention symptoms and comorbid mental disorders in adulthood were more related to long-term work disability. Study III: Among stimulant-naïve adults with ADHD 70% continued on medication at one-year follow-up, and treatment with stimulants or atomoxetine was associated with a clinically significant reduction in ADHD symptoms and mental distress, and improvement on measure of global function. In a general clinical setting one-year treatment with ADHD medications were associated with significant improvements of patients who continued on medication compared with those who discontinued. Given the nature of an open-label uncontrolled design, this calls for more controlled studies on medical treatment in a longer time perspective. List of papers. Papers I and III are removed from the thesis due to publisher restrictions. Paper I based on Study I. Fredriksen M, Halmoy A, Faraone SV, Haavik J. Long-term efficacy and safety of treatment with stimulants and atomoxetine in adult ADHD: A review of controlled and naturalistic studies. Eur Neuropsychopharmacol 2013;23:508-27. doi:10.1016/j.euroneuro.2012.07.016 Paper II based on Study II. Fredriksen M, Dahl AA, Martinsen EW, Klungsøyr O, Faraone SV, Peleikis DE. Childhood and persistent ADHD symptoms associated with educational failure and long-term occupational disability in adult ADHD. ADHD Atten Def Hyp Disord 2014 Jun;6(2):87-99. doi:10.1007/s12402-014-0126-1 Copyright The Author(s) 2014. This article is published with open access at Paper III based on Study III. Fredriksen M, Dahl AA, Martinsen EW, Klungsøyr O, Haavik J, Peleikis DE. Effectiveness of one-year pharmacological treatment of adult attention-deficit/hyperactivity disorder (ADHD): An open-label prospective study of time in treatment, dose, side-effects and comorbidity. Eur Neuropsychopharmacol, submitted 2014. Permanent link:
    06/2014, Degree: PhD, Supervisor: Dawn E. Peleikis, Alv A. Dahl, Egil W. Martinsen
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