Katelijne van Emmerik-van Oortmerssen

Prevalence of attention-deficit hyperactivity disorder in substance use disorder patients: A meta-analysis and meta-regression analysis

CONTEXT Substance use disorders (SUD) are a major public health problem. Attention deficit hyperactivity disorder (ADHD) is a comorbid condition associated with both onset and prognosis of SUD. Prevalence estimates of ADHD in SUD vary significantly. OBJECTIVE To obtain a best estimate of the prevalence of ADHD in SUD populations. DATA SOURCES A literature search was conducted using MEDLINE, PsycINFO and EMBASE. Search terms were ADHD, substance-related disorders, addiction, drug abuse, drug dependence, alcohol abuse, alcoholism, comorbidity, and prevalence. Results were limited to the English language. STUDY SELECTION After assessing the quality of the retrieved studies, 29 studies were selected. Studies in which nicotine was the primary drug of abuse were not included. DATA EXTRACTION All relevant data were extracted and analysed in a meta-analysis. A series of meta-regression analyses was performed to evaluate the effect of age, primary substance of abuse, setting and assessment procedure on the prevalence of ADHD in a variety of SUD populations. DATA SYNTHESIS Overall, 23.1% (CI: 19.4-27.2%) of all SUD subjects met DSM-criteria for comorbid ADHD. Cocaine dependence was associated with lower ADHD prevalence than alcohol dependence, opioid dependence and other addictions. Studies using the DICA or the SADS-L for the diagnosis of ADHD showed significantly higher comorbidity rates than studies using the KSADS, DISC, DIS or other assessment instruments. CONCLUSIONS ADHD is present in almost one out of every four patients with SUD. The prevalence estimate is dependent on substance of abuse and assessment instrument.

Variability in the prevalence of adult ADHD in treatment seeking substance use disorder patients: Results from an international multi-center study exploring DSM-IV and DSM-5 criteria

Background Available studies vary in their estimated prevalence of attention deficit/hyperactivity disorder (ADHD) in substance use disorder (SUD) patients, ranging from 2 to 83%. A better understanding of the possible reasons for this variability and the effect of the change from DSM-IV to DSM-5 is needed. Methods A two stage international multi-center, cross-sectional study in 10 countries, among patients form inpatient and outpatient addiction treatment centers for alcohol and/or drug use disorder patients. A total of 3558 treatment seeking SUD patients were screened for adult ADHD. A subsample of 1276 subjects, both screen positive and screen negative patients, participated in a structured diagnostic interview. Results Prevalence of DSM-IV and DSM-5 adult ADHD varied for DSM-IV from 5.4% (CI 95%: 2.4–8.3) for Hungary to 31.3% (CI 95%:25.2–37.5) for Norway and for DSM-5 from 7.6% (CI 95%: 4.1–11.1) for Hungary to 32.6% (CI 95%: 26.4–38.8) for Norway. Using the same assessment procedures in all countries and centers resulted in substantial reduction of the variability in the prevalence of adult ADHD reported in previous studies among SUD patients (2–83%→ 5.4–31.3%). The remaining variability was partly explained by primary substance of abuse and by country (Nordic versus non-Nordic countries). Prevalence estimates for DSM-5 were slightly higher than for DSM-IV. Conclusions Given the generally high prevalence of adult ADHD, all treatment seeking SUD patients should be screened and, after a confirmed diagnosis, treated for ADHD since the literature indicates poor prognoses of SUD in treatment seeking SUD patients with ADHD.

The obsessive compulsive spectrum in schizophrenia, a meta-analysis and meta-regression exploring prevalence rates

AIMS The aims of this study were to conduct a meta-analysis and meta-regression to estimate the prevalence rates for obsessive compulsive symptoms (OCS) and obsessive compulsive disorder (OCD) in schizophrenia, and to investigate what influences these prevalence rates. METHOD Studies were identified via an online OVID database search, including PsychInfo, Embase and Medline until December 2009. RESULTS Forty-three studies summarizing outcomes for 3978 subjects met inclusion criteria. The mean OCD prevalence is 12.3%, slightly increasing to 13.6% after adjustment in meta-regression. The prevalence rate of OCS, defined as any obsession or compulsion is 30.7% (30.3% adjusted). Higher severity of OCS, DIGS assessment, and Sub-Saharan African origin of study are associated with a lower OCS/OCD prevalence rate, use of DSM-IV edition, Y-BOCS assessment and longer schizophrenia history are associated with a higher prevalence rate. CONCLUSION The prevalence of OCS and OCD in schizophrenia is substantial, specifically in more chronic patient populations and is influenced by the method of assessment.

Validity of the Adult ADHD Self-Report Scale (ASRS) as a screener for adult ADHD in treatment seeking substance use disorder patients

BACKGROUND To detect attention deficit hyperactivity disorder (ADHD) in treatment seeking substance use disorders (SUD) patients, a valid screening instrument is needed. OBJECTIVES To test the performance of the Adult ADHD Self-Report Scale V 1.1(ASRS) for adult ADHD in an international sample of treatment seeking SUD patients for DSM-IV-TR; for the proposed DSM-5 criteria; in different subpopulations, at intake and 1-2 weeks after intake; using different scoring algorithms; and different externalizing disorders as external criterion (including adult ADHD, bipolar disorder, antisocial and borderline personality disorder). METHODS In 1138 treatment seeking SUD subjects, ASRS performance was determined using diagnoses based on Conners Adult ADHD Diagnostic Interview for DSM-IV (CAADID) as gold standard. RESULTS The prevalence of adult ADHD was 13.0% (95% CI: 11.0-15.0%). The overall positive predictive value (PPV) of the ASRS was 0.26 (95% CI: 0.22-0.30), the negative predictive value (NPV) was 0.97 (95% CI: 0.96-0.98). The sensitivity (0.84, 95% CI: 0.76-0.88) and specificity (0.66, 95% CI: 0.63-0.69) measured at admission were similar to the sensitivity (0.88, 95% CI: 0.83-0.93) and specificity (0.67, 95% CI: 0.64-0.70) measured 2 weeks after admission. Sensitivity was similar, but specificity was significantly better in patients with alcohol compared to (illicit) drugs as the primary substance of abuse (0.76 vs. 0.56). ASRS was not a good screener for externalizing disorders other than ADHD. CONCLUSIONS The ASRS is a sensitive screener for identifying possible ADHD cases with very few missed cases among those screening negative in this population.

Impulsivity in adult ADHD patients with and without cocaine dependence.

BACKGROUND Attention deficit hyperactivity disorder (ADHD) is present in about a quarter of patients with a substance use disorder (SUD) and impulsivity is a key feature of both disorders. However, very little is known about differences in impulse control and other cognitive functions between ADHD patients with and without SUD. METHODS In adult male medication-naïve ADHD patients with and without comorbid cocaine dependence and healthy controls (matched on gender, age and IQ), we measured motor impulsivity (stop signal task), cognitive impulsivity (delay discounting task), divided attention (trail making test), interference (Stroop task), working memory (n-back task), and time reproduction (time reproduction task). Additionally, self-reported ADHD symptoms (using the ADHD Symptom Rating Scale; ASRS) and self-reported impulsivity (Barratt Impulsivity Scale; BIS) were assessed. RESULTS Significantly higher levels of motor and cognitive impulsivity were found in ADHD patients with comorbid cocaine dependence compared to ADHD patients without cocaine dependence and controls, and both measures of impulsivity were highly correlated. No significant group differences were found on other cognitive measures. With regard to the self-report measures, only BIS attention subscores differed significantly between ADHD patients with and without cocaine dependence. ASRS and BIS scores were not significantly correlated. CONCLUSION This is the first study showing that ADHD patients with cocaine dependence are a distinctly more impulsive subpopulation compared to ADHD patients without cocaine dependence on objective measures of impulsivity. These findings are relevant to optimize psycho-education and treatment of ADHD patients with comorbid SUD.

Substrates of neuropsychological functioning in stimulant dependence: a review of functional neuroimaging research

Stimulant dependence is associated with neuropsychological impairments. Here, we summarize and integrate the existing neuroimaging literature on the neural substrates of neuropsychological (dys)function in stimulant dependence, including cocaine, (meth‐)amphetamine, ecstasy and nicotine dependence, and excessive caffeine use, comparing stimulant abusers (SAs) to nondrug using healthy controls (HCs). Despite some inconsistencies, most studies indicated altered brain activation in prefrontal cortex (PFC) and insula in response to reward and punishment, and higher limbic and anterior cingulate cortex (ACC)/PFC activation during craving and attentional bias paradigms in SAs compared with HCs. Impulsivity in SAs was associated with lower ACC and presupplementary motor area activity compared with HCs, and related to both ventral (amygdala, ventrolateral PFC, insula) and dorsal (dorsolateral PFC, dorsal ACC, posterior parietal cortex) systems. Decision making in SAs was associated with low dorsolateral PFC activity and high orbitofrontal activity. Finally, executive function in SAs was associated with lower activation in frontotemporal regions and higher activation in premotor cortex compared with HCs. It is concluded that the lower activations compared with HCs are likely to reflect the neural substrate of impaired neurocognitive functions, whereas higher activations in SAs compared with HCs are likely to reflect compensatory cognitive control mechanisms to keep behavioral task performance to a similar level as in HCs. However, before final conclusions can be drawn, additional research is needed using neuroimaging in SAs and HCs using larger and more homogeneous samples as well as more comparable task paradigms, study designs, and statistical analyses.

The International ADHD in Substance Use Disorders Prevalence (IASP) study: Background, methods and study population

Attention deficit/hyperactivity disorder (ADHD) is an increasingly recognized comorbid condition in subjects with substance use disorders (SUDs).

Investigating the efficacy of integrated cognitive behavioral therapy for adult treatment seeking substance use disorder patients with comorbid ADHD: study protocol of a randomized controlled trial

BackgroundAttention deficit hyperactivity disorder (ADHD) frequently co-occurs with substance use disorders (SUD). The combination of ADHD and SUD is associated with a negative prognosis of both SUD and ADHD. Pharmacological treatments of comorbid ADHD in adult patients with SUD have not been very successful. Recent studies show positive effects of cognitive behavioral therapy (CBT) in ADHD patients without SUD, but CBT has not been studied in ADHD patients with comorbid SUD.Methods/designThis paper presents the protocol of a randomized controlled trial to test the efficacy of an integrated CBT protocol aimed at reducing SUD as well as ADHD symptoms in SUD patients with a comorbid diagnosis of ADHD. The experimental group receives 15 CBT sessions directed at symptom reduction of SUD as well as ADHD. The control group receives treatment as usual, i.e. 10 CBT sessions directed at symptom reduction of SUD only. The primary outcome is the level of self-reported ADHD symptoms. Secondary outcomes include measures of substance use, depression and anxiety, quality of life, health care consumption and neuropsychological functions.DiscussionThis is the first randomized controlled trial to test the efficacy of an integrated CBT protocol for adult SUD patients with a comorbid diagnosis of ADHD. The rationale for the trial, the design, and the strengths and limitations of the study are discussed.Trial registrationThis trial is registered in http://www.clinicaltrials.gov as NCT01431235.

Low dopamine transporter occupancy by methylphenidate as a possible reason for reduced treatment effectiveness in ADHD patients with cocaine dependence

Methylphenidate (MPH) occupies brain striatal dopamine transporters (DATs) and is an effective treatment for attention deficit hyperactivity disorder (ADHD). However, patients with ADHD and comorbid cocaine dependence do not benefit significantly from treatment with MPH. To better understand the neurobiology of this phenomenon, we examined DAT availability and the effects of MPH treatment on DAT occupancy in ADHD patients with and without cocaine dependence. ADHD patients without a comorbid substance use disorder (N=16) and ADHD patients with comorbid cocaine dependence (N=8) were imaged at baseline and after two weeks MPH treatment using single photon emission computed tomography (SPECT) with the DAT tracer [(123)I]FP-CIT. Changes in ADHD symptoms were measured with the ADHD symptom rating scale (ASRS). At baseline, we observed lower striatal DAT availability in ADHD patients with cocaine dependence. Following fixed MPH treatment, MPH occupied significantly less striatal DATs in cocaine-dependent than in non-cocaine dependent ADHD patients. There were no significant correlations between baseline DAT availability or DAT occupancy by MPH and ADHD symptom improvement. However, we did find significant correlations between DAT occupancy by MPH and decreases in impulsivity scores and years of cocaine use. These preliminary findings suggest that low DAT occupancy is not the reason why ADHD patients with cocaine dependence do not benefit from MPH treatment. It also suggests that higher dosages of MPH in these patients are probably not the solution and that medications directed at other pharmacological targets should be considered in these comorbid ADHD patients. This trial is registered at the Dutch Trial Register, www.trialregister.nl, under Trial ID number NTR3127.

Persistence and Subtype Stability of ADHD Among Substance Use Disorder Treatment Seekers

Objective: To examine ADHD symptom persistence and subtype stability among substance use disorder (SUD) treatment seekers. Method: In all, 1,276 adult SUD treatment seekers were assessed for childhood and adult ADHD using Conners’ Adult ADHD Diagnostic Interview for Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; CAADID). A total of 290 (22.7%) participants met CAADID criteria for childhood ADHD and comprise the current study sample. Results: Childhood ADHD persisted into adulthood in 72.8% (n = 211) of cases. ADHD persistence was significantly associated with a family history of ADHD, and the presence of conduct disorder and antisocial personality disorder. The combined subtype was the most stable into adulthood (78.6%) and this stability was significantly associated with conduct disorder and past treatment of ADHD. Conclusion: ADHD is highly prevalent and persistent among SUD treatment seekers and is associated with the more severe phenotype that is also less likely to remit. Routine screening and follow-up assessment for ADHD is indicated to enhance treatment management and outcomes.