Consider ADHD in adult nonpsychotic psychiatric outpatients

BERLIN – The prevalence of attention-deficit/hyperactivity disorder among nonpsychotic adults in outpatient settings is markedly higher than in the general adult population, according to a major eight-nation observational study.

“I think this is a wake-up call for clinicians to include adult ADHD in their differential diagnostic considerations in a broad range of psychiatric patients,” Dr. Johannes Thome said in presenting the ADPSYC study results at the annual congress of the European College of Neuropsychopharmacology.

The study included 2,284 unselected participants in eight European countries. Nonpsychotic patients in outpatient care for any psychiatric disorder were eligible. A variety of outpatient settings were deliberately included: private psychiatric practices, community mental health centers, outpatient psychiatric clinics associated with medical centers, and outpatient clinics linked with psychiatric hospitals.

Participants were asked whether they’d ever been diagnosed with ADHD and also were screened using the Adult ADHD Self-Report Scale. If ADHD was suspected on either basis, they were further assessed using the Diagnostic Interview for ADHD in Adults, upon which the diagnosis hinged.

A total of 15.8% of the psychiatric outpatients were diagnosed with adult ADHD based on the criteria of the DSM-IV, 4th edition, as were 17.4% using DSM-5 criteria. In contrast, the consensus estimate of the prevalence of ADHD in the general adult population is 2.5%.

By DSM-IV criteria, 4.7% of the total ADPSYC population had the inattentive subtype of ADHD, 1.1% had the hyperactive/impulsive subtype, and 10% had the combined form, reported Dr. Thome, professor and chair of the department of psychiatry at the University of Rostock in Germany.

As is seen in the general population, the prevalence of ADHD in psychiatric outpatients was lower in women: 14.4%, compared with 21.6% among men. Illustrating the dictum that ADHD runs in families, 14.9% of patients with ADHD had a first-degree relative who’d been diagnosed with the disorder, as did just 3.7% of psychiatric outpatients without ADHD.

Twenty percent of patients with ADHD met criteria for substance abuse or dependence, compared with 12.6% of non-ADHD patients.

Quality of life and disability burden were assessed in all ADPSYC participants via the Clinical Global Impressions-Severity scale, (CGI-S); the Sheehan Disability Scale; and the EuroQol-5 Dimension questionnaire. These metrics showed that adult psychiatric outpatients with ADHD had significantly worse quality of life and more overall disability than outpatients without ADHD. For example, the mean CGI-S score in outpatients with ADHD was 3.8, compared with 3.3 in outpatients without ADHD. Sixty-four percent of outpatients with ADHD had scores placing them in the moderately, markedly, or severely ill range, compared with 47% of psychiatric patients without ADHD.

Moreover, the mean total score on the Sheehan Disability Scale averaged 18.9 in outpatients with ADHD, compared with 11.6 in psychiatric patients without ADHD. Those with ADHD scored markedly worse in multiple domains, including social life, family life, work/school, and underproductive days in the past week.

On the EuroQol-5 Dimension questionnaire, 25% of patients with ADHD reported being extremely anxious or depressed, compared with 16% without ADHD, Dr. Thome continued.

He emphasized that these quality of life impairment and disability scores highlight a key point about adult ADHD, one that applies to affected patients regardless of whether or not they have a comorbid psychiatric disorder: The impact of adult ADHD extends well beyond the core symptoms.

While ADHD by definition in the DSM-5 must start before age 12, “You have to expect that the older an affected patient gets, the more social problems will occur and the more comorbidity you’ll see,” he observed.

“If you are a clinician, you will probably never, ever find a patient who comes to you and says, ‘Doctor, I’m suffering from inattention, and I’m so impulsive, and my mood regulation doesn’t work well.’ Rather, they’ll come to you and say, ‘I have a problem at my workplace; I’m always having arguments with my boss and with my wife,’ ” according to the psychiatrist. “From the patient’s perspective, usually it’s much more important how their quality of life changes with treatment, rather than how much certain ADHD scales change.”

Along those lines, it’s important to note that numerous studies have demonstrated that individuals with adult ADHD have three times more emergency department visits, a 10-fold greater rate of outpatient medical visits, and three times more inpatient hospitalizations than the general adult population. They also have an increased risk of serious motor vehicle accidents, which appears to be reduced with the use of ADHD medications (JAMA Psychiatry 2014;71:319-25). A study by Dr. Thome and his colleagues showed that adult ADHD is also accompanied by significant alterations in circadian rhythms at the endocrine, genetic, and behavioral levels (Mol. Psychiatry 2012;17:988-95), which may in part explain the patients’ propensity for mishaps.

Moreover, a major Swedish national registry study involving more than 25,000 patients with adult ADHD established that the disorder is associated with increased rates of criminality, and that during periods when patients were on ADHD medications, their risk of arrests and convictions was significantly reduced (N. Engl. J. Med. 2012;367:2006-14). But while this study drew extensive media attention, heralding a “treatment for criminality,” Dr. Thome cautioned that association in an observational study does not prove causality.

“Some people argue that because they can’t focus and are so impatient, people with adult ADHD are simply worse at hiding the crime and are much more easily caught by the police, and that during periods when they’re on medication they are more likely to be seeing a social worker or have other social support. That might be a partial explanation,” Dr. Thome said. “But my main point here is I want you to understand that you don’t need to be afraid of adult ADHD patients. They’re not more dangerous than others.”

With regard to treatment, he emphasized that a comprehensive plan for adult ADHD needs to address psychological, behavioral, and educational or occupational needs with a range of interventions.

“I want to make the point that psychologic therapy is at least as important as medication,” Dr. Thome said. “Pills don’t give you skills.”

The ADPSYC study was funded by Eli Lilly. Dr. Thome reported having received research grants and/or serving on advisory boards for Lilly and more than a dozen other companies.

bjancin@frontlinemedcom.com

BERLIN – The prevalence of attention-deficit/hyperactivity disorder among nonpsychotic adults in outpatient settings is markedly higher than in the general adult population, according to a major eight-nation observational study.

“I think this is a wake-up call for clinicians to include adult ADHD in their differential diagnostic considerations in a broad range of psychiatric patients,” Dr. Johannes Thome said in presenting the ADPSYC study results at the annual congress of the European College of Neuropsychopharmacology.

The study included 2,284 unselected participants in eight European countries. Nonpsychotic patients in outpatient care for any psychiatric disorder were eligible. A variety of outpatient settings were deliberately included: private psychiatric practices, community mental health centers, outpatient psychiatric clinics associated with medical centers, and outpatient clinics linked with psychiatric hospitals.

Participants were asked whether they’d ever been diagnosed with ADHD and also were screened using the Adult ADHD Self-Report Scale. If ADHD was suspected on either basis, they were further assessed using the Diagnostic Interview for ADHD in Adults, upon which the diagnosis hinged.

A total of 15.8% of the psychiatric outpatients were diagnosed with adult ADHD based on the criteria of the DSM-IV, 4th edition, as were 17.4% using DSM-5 criteria. In contrast, the consensus estimate of the prevalence of ADHD in the general adult population is 2.5%.

By DSM-IV criteria, 4.7% of the total ADPSYC population had the inattentive subtype of ADHD, 1.1% had the hyperactive/impulsive subtype, and 10% had the combined form, reported Dr. Thome, professor and chair of the department of psychiatry at the University of Rostock in Germany.

As is seen in the general population, the prevalence of ADHD in psychiatric outpatients was lower in women: 14.4%, compared with 21.6% among men. Illustrating the dictum that ADHD runs in families, 14.9% of patients with ADHD had a first-degree relative who’d been diagnosed with the disorder, as did just 3.7% of psychiatric outpatients without ADHD.

Twenty percent of patients with ADHD met criteria for substance abuse or dependence, compared with 12.6% of non-ADHD patients.

Quality of life and disability burden were assessed in all ADPSYC participants via the Clinical Global Impressions-Severity scale, (CGI-S); the Sheehan Disability Scale; and the EuroQol-5 Dimension questionnaire. These metrics showed that adult psychiatric outpatients with ADHD had significantly worse quality of life and more overall disability than outpatients without ADHD. For example, the mean CGI-S score in outpatients with ADHD was 3.8, compared with 3.3 in outpatients without ADHD. Sixty-four percent of outpatients with ADHD had scores placing them in the moderately, markedly, or severely ill range, compared with 47% of psychiatric patients without ADHD.

Moreover, the mean total score on the Sheehan Disability Scale averaged 18.9 in outpatients with ADHD, compared with 11.6 in psychiatric patients without ADHD. Those with ADHD scored markedly worse in multiple domains, including social life, family life, work/school, and underproductive days in the past week.

On the EuroQol-5 Dimension questionnaire, 25% of patients with ADHD reported being extremely anxious or depressed, compared with 16% without ADHD, Dr. Thome continued.

He emphasized that these quality of life impairment and disability scores highlight a key point about adult ADHD, one that applies to affected patients regardless of whether or not they have a comorbid psychiatric disorder: The impact of adult ADHD extends well beyond the core symptoms.

While ADHD by definition in the DSM-5 must start before age 12, “You have to expect that the older an affected patient gets, the more social problems will occur and the more comorbidity you’ll see,” he observed.

“If you are a clinician, you will probably never, ever find a patient who comes to you and says, ‘Doctor, I’m suffering from inattention, and I’m so impulsive, and my mood regulation doesn’t work well.’ Rather, they’ll come to you and say, ‘I have a problem at my workplace; I’m always having arguments with my boss and with my wife,’ ” according to the psychiatrist. “From the patient’s perspective, usually it’s much more important how their quality of life changes with treatment, rather than how much certain ADHD scales change.”

Along those lines, it’s important to note that numerous studies have demonstrated that individuals with adult ADHD have three times more emergency department visits, a 10-fold greater rate of outpatient medical visits, and three times more inpatient hospitalizations than the general adult population. They also have an increased risk of serious motor vehicle accidents, which appears to be reduced with the use of ADHD medications (JAMA Psychiatry 2014;71:319-25). A study by Dr. Thome and his colleagues showed that adult ADHD is also accompanied by significant alterations in circadian rhythms at the endocrine, genetic, and behavioral levels (Mol. Psychiatry 2012;17:988-95), which may in part explain the patients’ propensity for mishaps.

Moreover, a major Swedish national registry study involving more than 25,000 patients with adult ADHD established that the disorder is associated with increased rates of criminality, and that during periods when patients were on ADHD medications, their risk of arrests and convictions was significantly reduced (N. Engl. J. Med. 2012;367:2006-14). But while this study drew extensive media attention, heralding a “treatment for criminality,” Dr. Thome cautioned that association in an observational study does not prove causality.

“Some people argue that because they can’t focus and are so impatient, people with adult ADHD are simply worse at hiding the crime and are much more easily caught by the police, and that during periods when they’re on medication they are more likely to be seeing a social worker or have other social support. That might be a partial explanation,” Dr. Thome said. “But my main point here is I want you to understand that you don’t need to be afraid of adult ADHD patients. They’re not more dangerous than others.”

With regard to treatment, he emphasized that a comprehensive plan for adult ADHD needs to address psychological, behavioral, and educational or occupational needs with a range of interventions.

“I want to make the point that psychologic therapy is at least as important as medication,” Dr. Thome said. “Pills don’t give you skills.”

The ADPSYC study was funded by Eli Lilly. Dr. Thome reported having received research grants and/or serving on advisory boards for Lilly and more than a dozen other companies.

bjancin@frontlinemedcom.com

BERLIN – The prevalence of attention-deficit/hyperactivity disorder among nonpsychotic adults in outpatient settings is markedly higher than in the general adult population, according to a major eight-nation observational study.

“I think this is a wake-up call for clinicians to include adult ADHD in their differential diagnostic considerations in a broad range of psychiatric patients,” Dr. Johannes Thome said in presenting the ADPSYC study results at the annual congress of the European College of Neuropsychopharmacology.

The study included 2,284 unselected participants in eight European countries. Nonpsychotic patients in outpatient care for any psychiatric disorder were eligible. A variety of outpatient settings were deliberately included: private psychiatric practices, community mental health centers, outpatient psychiatric clinics associated with medical centers, and outpatient clinics linked with psychiatric hospitals.

Participants were asked whether they’d ever been diagnosed with ADHD and also were screened using the Adult ADHD Self-Report Scale. If ADHD was suspected on either basis, they were further assessed using the Diagnostic Interview for ADHD in Adults, upon which the diagnosis hinged.

A total of 15.8% of the psychiatric outpatients were diagnosed with adult ADHD based on the criteria of the DSM-IV, 4th edition, as were 17.4% using DSM-5 criteria. In contrast, the consensus estimate of the prevalence of ADHD in the general adult population is 2.5%.

By DSM-IV criteria, 4.7% of the total ADPSYC population had the inattentive subtype of ADHD, 1.1% had the hyperactive/impulsive subtype, and 10% had the combined form, reported Dr. Thome, professor and chair of the department of psychiatry at the University of Rostock in Germany.

As is seen in the general population, the prevalence of ADHD in psychiatric outpatients was lower in women: 14.4%, compared with 21.6% among men. Illustrating the dictum that ADHD runs in families, 14.9% of patients with ADHD had a first-degree relative who’d been diagnosed with the disorder, as did just 3.7% of psychiatric outpatients without ADHD.

Twenty percent of patients with ADHD met criteria for substance abuse or dependence, compared with 12.6% of non-ADHD patients.

Quality of life and disability burden were assessed in all ADPSYC participants via the Clinical Global Impressions-Severity scale, (CGI-S); the Sheehan Disability Scale; and the EuroQol-5 Dimension questionnaire. These metrics showed that adult psychiatric outpatients with ADHD had significantly worse quality of life and more overall disability than outpatients without ADHD. For example, the mean CGI-S score in outpatients with ADHD was 3.8, compared with 3.3 in outpatients without ADHD. Sixty-four percent of outpatients with ADHD had scores placing them in the moderately, markedly, or severely ill range, compared with 47% of psychiatric patients without ADHD.

Moreover, the mean total score on the Sheehan Disability Scale averaged 18.9 in outpatients with ADHD, compared with 11.6 in psychiatric patients without ADHD. Those with ADHD scored markedly worse in multiple domains, including social life, family life, work/school, and underproductive days in the past week.

On the EuroQol-5 Dimension questionnaire, 25% of patients with ADHD reported being extremely anxious or depressed, compared with 16% without ADHD, Dr. Thome continued.

He emphasized that these quality of life impairment and disability scores highlight a key point about adult ADHD, one that applies to affected patients regardless of whether or not they have a comorbid psychiatric disorder: The impact of adult ADHD extends well beyond the core symptoms.

While ADHD by definition in the DSM-5 must start before age 12, “You have to expect that the older an affected patient gets, the more social problems will occur and the more comorbidity you’ll see,” he observed.

“If you are a clinician, you will probably never, ever find a patient who comes to you and says, ‘Doctor, I’m suffering from inattention, and I’m so impulsive, and my mood regulation doesn’t work well.’ Rather, they’ll come to you and say, ‘I have a problem at my workplace; I’m always having arguments with my boss and with my wife,’ ” according to the psychiatrist. “From the patient’s perspective, usually it’s much more important how their quality of life changes with treatment, rather than how much certain ADHD scales change.”

Along those lines, it’s important to note that numerous studies have demonstrated that individuals with adult ADHD have three times more emergency department visits, a 10-fold greater rate of outpatient medical visits, and three times more inpatient hospitalizations than the general adult population. They also have an increased risk of serious motor vehicle accidents, which appears to be reduced with the use of ADHD medications (JAMA Psychiatry 2014;71:319-25). A study by Dr. Thome and his colleagues showed that adult ADHD is also accompanied by significant alterations in circadian rhythms at the endocrine, genetic, and behavioral levels (Mol. Psychiatry 2012;17:988-95), which may in part explain the patients’ propensity for mishaps.

Moreover, a major Swedish national registry study involving more than 25,000 patients with adult ADHD established that the disorder is associated with increased rates of criminality, and that during periods when patients were on ADHD medications, their risk of arrests and convictions was significantly reduced (N. Engl. J. Med. 2012;367:2006-14). But while this study drew extensive media attention, heralding a “treatment for criminality,” Dr. Thome cautioned that association in an observational study does not prove causality.

“Some people argue that because they can’t focus and are so impatient, people with adult ADHD are simply worse at hiding the crime and are much more easily caught by the police, and that during periods when they’re on medication they are more likely to be seeing a social worker or have other social support. That might be a partial explanation,” Dr. Thome said. “But my main point here is I want you to understand that you don’t need to be afraid of adult ADHD patients. They’re not more dangerous than others.”

With regard to treatment, he emphasized that a comprehensive plan for adult ADHD needs to address psychological, behavioral, and educational or occupational needs with a range of interventions.

“I want to make the point that psychologic therapy is at least as important as medication,” Dr. Thome said. “Pills don’t give you skills.”

The ADPSYC study was funded by Eli Lilly. Dr. Thome reported having received research grants and/or serving on advisory boards for Lilly and more than a dozen other companies.

bjancin@frontlinemedcom.com