Denise Bijlenga

Associations between sleep characteristics, seasonal depressive symptoms, lifestyle, and ADHD symptoms in adults.

Objective: The authors explored associations between ADHD symptoms, seasonal depressive symptoms, lifestyle, and health. Method: Adult ADHD patients (n = 202) and controls (n = 189) completed the ASESA questionnaire involving lifestyle, eating pattern, and physical and psychological health, and validated measures on ADHD and sleep. ASESA is the Dutch acronym for Inattention, Sleep, Eating pattern, Mood, and General health questionnaire. Results: Indication for delayed sleep phase syndrome (DSPS) was 26% in patients and 2% in controls (p < .001). Patients reported shorter sleep, longer sleep-onset latency, and later midsleep. Shorter (R2 = .21) and later (R2 = .27) sleep were associated with hyperactivity, male gender, younger age, and seasonal depressive symptoms. Seasonal depressive symptoms were related to hyperactivity, female gender, unemployment, and late sleep (pseudo R2 = .28). Higher body mass index (BMI) was associated with shorter sleep in patients (ρ = −.16; p = .04) and controls (ρ = −.17; p = .02). Longer sleep showed lower odds for indication of metabolic syndrome (OR = −0.17; p = .053). Conclusion: DSPS is more prevalent in ADHD and needs further investigation to establish treatment to prevent chronic health issues.

Body temperature, activity and melatonin profiles in adults with attention-deficit/hyperactivity disorder and delayed sleep: a case-control study

Irregular sleep–wake patterns and delayed sleep times are common in adults with attention‐deficit/hyperactivity disorder, but mechanisms underlying these problems are unknown. The present case–control study examined whether circadian abnormalities underlie these sleep problems in a naturalistic home setting. We included 12 medication‐naïve patients with attention‐deficit/hyperactivity disorder and delayed sleep phase syndrome, and 12 matched healthy controls. We examined associations between sleep/wake rhythm in attention‐deficit/hyperactivity disorder and circadian parameters (i.e. salivary melatonin concentrations, core and skin temperatures, and activity patterns) of the patients and controls during five consecutive days and nights. Daily bedtimes were more variable within patients compared with controls (F = 8.19, P < 0.001), but melatonin profiles were equally stable within individuals. Dim‐light melatonin onset was about 1.5 h later in the patient group (U = 771, Z = −4.63, P < 0.001). Patients slept about 1 h less on nights before work days compared with controls (F = 11.21, P = 0.002). The interval between dim‐light melatonin onset and sleep onset was on average 1 h longer in patients compared with controls (U = 1117, Z = −2.62, P = 0.009). This interval was even longer in patients with extremely late chronotype. Melatonin, activity and body temperatures were delayed to comparable degrees in patients. Overall temperatures were lower in patients than controls. Sleep‐onset difficulties correlated with greater distal–proximal temperature gradient (DPG; i.e. colder hands, r2 = −0.32, P = 0.028) in patients. Observed day‐to‐day bedtime variability of individuals with attention‐deficit/hyperactivity disorder and delayed sleep phase syndrome were not reflected in their melatonin profiles. Irregular sleep–wake patterns and delayed sleep in individuals with attention‐deficit/hyperactivity disorder and delayed sleep phase syndrome are associated with delays and dysregulations of the core and skin temperatures.

The circadian rhythm in adult attention-deficit/hyperactivity disorder: current state of affairs

Adults with ADHD often have sleep problems that are caused by a delay of their internal circadian rhythm system. Such individuals are often typified as ‘evening’ or ‘night’ persons. This review focuses on the link between ADHD symptoms and the evening typology through multiple pathways. Etiology of the internal circadian rhythm system, the genetic basis for evening typology, overlap between ADHD symptoms and evening preference and risk factors for various chronic health conditions, including metabolic syndrome and cancer, are discussed. The treatment perspectives to reset the delayed rhythm in adults with ADHD involve psychoeducation on sleep hygiene, melatonin in the afternoon or evening and bright light therapy in the morning.

Circadian rhythm disruption as a link between Attention-Deficit/Hyperactivity Disorder and obesity?

OBJECTIVE Patients with Attention-Deficit/Hyperactivity Disorder (ADHD) have a high prevalence of obesity. This is the first study to investigate whether circadian rhythm disruption is a mechanism linking ADHD symptoms to obesity. METHODS ADHD symptoms and two manifestations of circadian rhythm disruption: sleep problems and an unstable eating pattern (skipping breakfast and binge eating later in the day) were assessed in participants with obesity (n= 114), controls (n= 154), and adult ADHD patients (n= 202). RESULTS Participants with obesity had a higher prevalence of ADHD symptoms and short sleep on free days as compared to controls, but a lower prevalence of ADHD symptoms, short sleep on free days, and an unstable eating pattern as compared to ADHD patients.We found that participants with obesity had a similar prevalence rate of an unstable eating pattern when compared to controls. Moreover, mediation analyses showed that both sleep duration and an unstable eating pattern mediated the association between ADHD symptoms and body mass index (BMI). CONCLUSION Our study supports the hypothesis that circadian rhythm disruption is a mechanism linking ADHD symptoms to obesity. Further research is needed to determine if treatment of ADHD and circadian rhythm disruption is effective in the prevention and treatment of obesity in patients with obesity and/or ADHD.

OROS-methylphenidate efficacy on specific executive functioning deficits in adults with ADHD: A randomized, placebo-controlled cross-over study.

Attention-deficit/hyperactivity disorder (ADHD) is linked to impaired executive functioning (EF). This is the first study to objectively investigate the effects of a long-acting methylphenidate on neurocognitive test performance of adults with ADHD. Twenty-two adults with ADHD participated in a 6-weeks study examining the effect of osmotic-release oral system methylphenidate (OROS-mph) on continuous performance tests (CPTs; objective measures), and on the self-reported ADHD rating scale (subjective measure) using a randomized, double-blind, placebo-controlled cross-over design. OROS-mph significantly improved reaction time variability (RTV), commission errors (CE) and d-prime (DP) as compared to baseline (Cohens d>.50), but did not affect hit reaction time (HRT) or omission errors (OE). Compared to placebo, OROS-mph only significantly influenced RTV on one of two CPTs (p<.050). Linear regression analyses showed predictive ability of more beneficial OROS-mph effects in ADHD patients with higher EF severity (RTV: β=.670, t=2.097, p=.042; omission errors (OE): β=-.098, t=-4.759, p<.001), and with more severe ADHD symptoms (RTV: F=6.363, p=.019; HRT: F=3.914, p=.061). Side effects rates were substantially but non-significantly greater for OROS-mph compared to placebo (77% vs. 46%, p=.063). OROS-mph effects indicated RTV as the most sensitive parameter for measuring both neuropsychological and behavioral deficits in adults with ADHD. These findings suggest RTV as an endophenotypic parameter for ADHD symptomatology, and propose CPTs as an objective method for monitoring methylphenidate titration.

High prevalence of self-reported photophobia in adult ADHD.

Many adult outpatients with attention-deficit/hyperactivity disorder (ADHD) report an oversensitivity to light. We explored the link between ADHD and photophobia in an online survey (N = 494). Self-reported photophobia was prevalent in 69% of respondents with, and in 28% of respondents without, ADHD (symptoms). The ADHD (symptoms) group wore sunglasses longer during daytime in all seasons. Photophobia may be related to the functioning of the eyes, which mediate dopamine and melatonin production systems in the eye. In the brain, dopamine and melatonin are involved in both ADHD and circadian rhythm disturbances. Possibly, the regulation of the dopamine and melatonin systems in the eyes and in the brain are related. Despite the study’s limitations, the results are encouraging for further study on the pathophysiology of ADHD, eye functioning, and circadian rhythm disturbances.

Prevalence of ADHD symptoms across clinical stages of major depressive disorder

BACKGROUND Depression and ADHD often co-occur in clinical samples. Depression severity may be linked to ADHD symptomatology. We therefore assessed ADHD symptoms across clinical stages of major depressive disorder (MDD). METHODS We used 4-year follow-up data of the Netherlands Study of Depression and Anxiety (September 2008 until April 2011), including healthy controls, groups with remitted and current MDD (N=2053; age range 21-69 years; 66.8% females). Probable ADHD was defined as having current ADHD symptoms on the Conners Adult ADHD Rating Scale and a positive score on childhood or early-adolescent ADHD indicators. We examined ADHD symptom rates across (i) those with and without lifetime MDD, (ii) clinical characteristics of MDD including severity, course and outcomes, (iii) clinical stages of MDD. RESULTS (i) The prevalence of ADHD symptoms was 0.4% in healthy controls, 5.7% in remitted MDD and 22.1% in current MDD (OR=4.5; 95% CI 3.1-6.5). (ii) ADHD symptom rates and odds were significantly increased among those with more severe depression (29.4%; OR=6.8; 95% CI 2.9-16.1), chronic depression (21.8%; OR=3.8; 95% CI 2.5-5.7), earlier age of onset of depressive symptoms (9.9%; OR=1.5; 95% CI 1.0-2.3), and comorbid anxiety disorders (29.0%; OR=3.4; 95% CI 2.0-5.7). (iii) ADHD symptom rates increased across clinical stages of MDD, up to 22.5% in chronic MDD. LIMITATIONS We used self-reports on ADHD symptoms. Also, clinical staging models have not yet been validated for mental disorders. CONCLUSIONS ADHD symptoms are very common among MDD patients, especially among those in recurrent and chronic stages of MDD. Considering ADHD may be an important step forward in improving the treatment of depression.

ADHD in old age: a review of the literature and proposal for assessment and treatment

ABSTRACT Introduction: ADHD is an often heritable, neurodevelopmental disorder with a prevalence of 4–5% in children and adults and about 3% in older adults. The disorder in older adults (> 55 years) is accompanied by similar comorbidities such as anxiety and depression, and social impairment as in younger age groups. Areas covered: An overview of the literature on diagnostic assessment, differential diagnosis, and treatment of older adults with ADHD is described. Case studies show that stimulant treatment is beneficial for ADHD in old age, but randomized controlled trials are lacking. Stimulant treatment has been studied in depression and even dementia in older adults, and seems safe with active cardiovascular risk management. In this paper, a proposal for diagnostic assessment and treatment is described for ADHD in older adults, including differential diagnosis with other psychiatric and neurocognitive disorders. Expert commentary: Regarding the organization of mental health, professionals in geriatric psychiatry need to be trained in assessment and treatment of ADHD in older age. Lifespan ADHD clinics may help patients of all ages to receive better specialized care.

Long-term relationship between methylphenidate and tobacco consumption and nicotine craving in adults with ADHD in a prospective cohort study

Patients with Attention-Deficit/Hyperactivity disorder (ADHD) have higher smoking rates, a younger age of smoking onset, and increased difficulty to stop smoking as compared to controls. Methylphenidate induced acute effects of increased smoking in laboratory studies, but long-term effects are unknown. We studied the acute and long-term relationship between methylphenidate use and tobacco consumption and nicotine craving among ADHD patients naïve for methylphenidate (N=325). Patients filled out the Smoking Questionnaire (SQ) at baseline, and after two-weeks and three-months of methylphenidate use. The SQ involved questions on demographics, tobacco consumption, nicotine craving, life events, psychiatric diagnoses and use of medication. At baseline, smoking prevalence of ADHD patients was twice as high (50.2%) as the national norm (25.6%; p<.001). Tobacco consumption increased with 1.3 cigarettes per day after three-months of methylphenidate use. When translated into pack years, tobacco consumption increased by about 23 packs per year. Reports of increased nicotine craving after methylphenidate, increased with 20.3% after two weeks and 29.2% after three months. Light smokers (1-12 cigarettes/day) were especially at risk for increased tobacco consumption (p<.05). Thus although methylphenidate is the drug of choice in medical treatment for ADHD, tobacco consumption and nicotine craving increased acutely and stabilized at increased levels after three-months of methylphenidate use. Although the net effect of methylphenidate on smoking behavior and craving should be further investigated within a randomized, placebo-controlled design, the results suggest that active prevention of increased smoking is needed in patients prescribed methylphenidate.

Individual Differences in the Post-Illumination Pupil Response to Blue Light : Assessment without Mydriatics

Melanopsin-containing retinal ganglion cells play an important role in the non-image forming effects of light, through their direct projections on brain circuits involved in circadian rhythms, mood and alertness. Individual differences in the functionality of the melanopsin-signaling circuitry can be reliably quantified using the maximum post-illumination pupil response (PIPR) after blue light. Previous protocols for acquiring PIPR relied on the use of mydriatics to dilate the light-exposed eye. However, pharmacological pupil dilation is uncomfortable for the participants and requires ophthalmological expertise. Hence, we here investigated whether an individual’s maximum PIPR can be validly obtained in a protocol that does not use mydriatics but rather increases the intensity of the light stimulus. In 18 participants (5 males, mean age ± SD: 34.6 ± 13.6 years) we evaluated the PIPR after exposure to intensified blue light (550 µW/cm2) provided to an undilated dynamic pupil. The test-retest reliability of the primary PIPR outcome parameter was very high, both between day-to-day assessments (Intraclass Correlation Coefficient (ICC) = 0.85), as well as between winter and summer assessments (ICC = 0.83). Compared to the PIPR obtained with the use of mydriatics and 160 µW/cm2 blue light exposure, the method with intensified light without mydriatics showed almost zero bias according to Bland-Altman plots and had moderate to strong reliability (ICC = 0.67). In conclusion, for PIPR assessments, increasing the light intensity is a feasible and reliable alternative to pupil dilation to relieve the participant’s burden and to allow for performance outside the ophthalmological clinic.