December 7, 2021
A team of German researchers explored five million member records from a database that tracks more than sixty nationwide statutory health insurance programs. The database closely tracks the characteristics of the overall German population.
This was a longitudinal cohort study, tracking individuals first diagnosed with adult ADHD between 2013 and 2017. Anyone who was not continuously insured during this period was excluded, as were those who died, plus anyone older than 55 to prevent bias from high morbidity in the top age brackets.
The study team used the database to add up direct healthcare costs, including inpatient care, outpatient care, psychotherapy, medical aids and remedies, medication, and sickness benefits. In Germany, sickness benefits kick in after more than six weeks of continuous inability to work.
The study tracked data within a window extending both four years back and four years forward from the initial adult ADHD diagnosis.
The resulting study cohort consisted of 2,380 persons between 18 and 55, initially diagnosed with ADHD at an average age of 35. Sixty percent were male.
One-third were prescribed ADHD medication upon diagnosis. Four years later, only one-eighth were still on medication.
Almost two-thirds received psychotherapy, dropping to under a third in succeeding years.
During the year following diagnosis, average healthcare costs totaled about €4,000 per individual. For those who initiated ADHD medication, the average cost was just over €5,400, and for those who did not it was almost €3,500.
The authors concluded, "An important finding of the present investigation is that in the year of initial diagnosis, less than one-third of individuals received any prescription of ADHD-specific medication, and only a fourth got at least two prescriptions. At the same time, almost two-thirds of individuals received psychotherapy in the year of ADHD[adult ADHD] diagnosis. In about one-third of individuals, psychotherapy had been initiated already before a diagnosis of ADHD, presumably for treatment of comorbid disorders. ... In current German guidelines, ADHD-specific medication is recommended as the first choice ... Apparently, despite the vast body of evidence for the beneficial effects of ADHD-specific medication, at least in the short-term, and in contrast to the recommendations of previous and current guidelines, stimulant medication is only reluctantly prescribed in newly identified adults with ADHD. ... Overall, our findings suggest that significant deficiencies may currently exist concerning the reality of healthcare for ADHD in Germany, and that guideline recommendations are not yet comprehensively implemented in everyday routine care."
Berit Libutzki, Benno Neukirch, Melanie May, Markus Gleitz, Michael Karus, Catharina A. Hartman, and Andreas Reif, "Diseaseburden and direct medical costs of incident adult ADHD: A retrospective longitudinal analysis based on German statutory health insurance claims data," EuropeanPsychiatry (2020),63(1), e86, 1-9, https://doi.org/10.1192/j.eurpsy.2020.84.
Recent research suggests that inflammation may play a role in ADHD. Inflammation, marked by elevated proteins and cytokines, affects brain development and structure. Evidence suggests it plays a role in the development of ADHD, making the study of inflammatory markers crucial.
The platelet-to-lymphocyte ratio (PLR) is a cost-effective test for predicting outcomes of chronic inflammation and neuroimmune diseases. Studies show PLR may be an important inflammatory marker in the pathophysiology of ADHD in children.
The Study:
A Chinese study team used the National Health and Nutrition Examination Survey (NHANES) database maintained by the National Center for Health Statistics of the United States to investigate the association between PLR and ADHD in children aged 6–14.
The team identified ADHD through prescriptions of ADHD medications.
After exclusions for missing information, the study encompassed 1,455 children.
The authors adjusted for the following potential confounders: sex, age, race, poverty-to-income ratio, maternal age at childbirth, smoking during pregnancy, asthma, health insurance status, dietary inflammatory index, monocyte count, segmented neutrophil count, eosinophil count, and basophil count.
They also split the PLR results into quartiles, with the first quartile having the lowest readings.
Prescriptions of ADHD medications were twice as frequent among children in the second quartile as they were among children in the first quartile. They were four times as frequent among children in the third quartile than among children in the first quartile.
Conclusion:
The team concluded, “These findings further support the potential role of inflammation in the onset and development of ADHD, providing preliminary evidence for PLR as a potential biomarker for ADHD and suggesting its possible use in identifying high-risk populations. However, considering the limitations of this study, future research should be designed as larger-scale, prospective, multi-center randomized controlled trials to validate these findings and further explore the relationship between inflammatory mechanisms and ADHD.”
In other words, this study suggests that while high PLR values may serve as a potential biomarker for ADHD, particularly in specific high-risk groups, further research is needed to confirm these findings and fully understand the role of inflammation in ADHD development. Larger, more robust studies will be crucial to validating PLR as a reliable tool for identifying at-risk populations.
ADHD is the most prevalent neurodevelopmental disorder. Nearly 1% of pregnant women in the Nordic countries and more than 1% in the United States are prescribed ADHD medications, ranking these among the most commonly used medications during pregnancy. However, the safety of exposing a fetus to ADHD medications is still uncertain, prompting many expectant mothers to stop using them out of fear for their unborn child’s well-being.
The Study:
A European research team conducted a comprehensive nationwide study on the safety of ADHD medications during pregnancy using populations from Sweden and Denmark. The Swedish population was studied first, followed by inclusion of a separate study of the Danish population. Results were then combined through meta-analysis. Nordic countries, with their single-payer national health insurance systems and national population registers, facilitate the tracking of residents’ health from birth to death, thus providing robust data for such studies.
The team accounted for various potential confounders, including maternal age, year of delivery, whether the mother was a first-time parent, self-reported smoking during pregnancy, and any psychiatric history. They also considered psychiatric inpatient or outpatient treatment received within two years before pregnancy, as well as the dispensing of other psychotropic medications during pregnancy, including antidepressants, antipsychotics, antiseizure medications, and anti-anxiety medications. Additionally, they examined the highest level of maternal education and civil status at delivery (married or cohabiting compared to single, divorced, or widowed).
Out of 861,650 Swedish children, 2,257 were exposed to ADHD medications during pregnancy. Another 3,917 were born to mothers who discontinued ADHD medications before pregnancy.
Children exposed to ADHD medications had lower rates of ADHD, autism spectrum disorder, and overall neurodevelopmental disorders; however, none of these differences were significant.
Limiting the analysis to siblings to control for family environmental influences and genetics likewise found no significant differences.
A meta-analysis combining the Swedish results with a separately conducted nationwide population study in neighboring Denmark similarly found no significant differences between children exposed to ADHD medications during pregnancy and children born to mothers who discontinued ADHD medications before pregnancy.
Conclusion:
The team concluded, “Overall, our study provides reassuring evidence that continuing ADHD medication during pregnancy does not increase the risk of long-term NDDs [neurodevelopmental disorders] in offspring."
A new large-scale study has shed light on which treatments for attention-deficit/hyperactivity disorder (ADHD) in adults are most effective and best tolerated.
Researchers analyzed 113 randomized controlled trials involving nearly 15,000 adults diagnosed with ADHD. These studies included medications (like stimulants and atomoxetine), psychological therapies (such as cognitive behavioral therapy), and newer approaches like neurostimulation.
The Findings
Stimulant medications (lisdexamfetamine and methylphenidate) as well as selective norepinephrine reuptake inhibitors (SNRI) (atomoxetine) were the only treatments that consistently reduced core ADHD symptoms—both from the perspective of patients and clinicians. It may be worth noting that atomoxetine, while effective, was less well tolerated, with more people dropping out due to side effects.
Psychological therapies such as CBT, mindfulness, and psychoeducation showed some benefits, but mainly according to clinician ratings—not necessarily from the patients themselves. Neurostimulation techniques like transcranial direct current stimulation also showed some improvements, but only in limited contexts and with small sample sizes. Interestingly, none of the treatments—medication or otherwise—made a clear impact on long-term quality of life or emotional regulation.
Conclusion
So, what does this mean for people navigating ADHD in adulthood? Stimulant medications remain the most effective treatment for managing ADHD symptoms day-to-day but nonstimulant medication are not far behind, which is good given the problems we’ve had with stimulant shortages. This study also supports structured psychotherapy as a viable treatment option, especially when used in conjunction with medication.
The study emphasizes the importance of ongoing, long-term research and the need for treatment plans that are tailored to the individual ADHD patient– Managing adult ADHD effectively calls for flexible, patient-centered care.
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