Stephen_Faraone_PhD_ADHD_in_AdultsEditor’s Note:  It is important to read the FULL Blog post.

Suicide is one of the most feared outcomes of any psychiatric condition.  Although its association with depression is well known, a small but growing research literature shows that ADHD is also a risk factor for suicidality.  

Suicide is difficult to study. Because it is relatively rare, large samples of patients are needed to make definitive statements.  Studies of suicide and ADHD must also consider the possibility that medications might elevate that risk. 

For example, the FDA placed a black box warning on atomoxetine because that ADHD medication had been shown to increase suicidal risk in youth.   A recent study of 37,936 patients with ADHD now provides much insight into these issues (Chen, Q., Sjolander, A., Runeson, B., D’Onofrio, B. M., Lichtenstein, P. & Larsson, H. (2014). Drug treatment for attention-deficit/hyperactivity disorder and suicidal behaviour: register based study. BMJ 348, g3769.).    In Sweden, such large studies are possible because researchers have computerized medical registers that describe the disorders and treatments of all people in Sweden.  Among 37,936 patients with ADHD, 7019 suicide attempts or completed suicides occurred during 150,721 person years of follow-up.  This indicates that, in any given year, the risk for a suicidal event is about 5%. 

 

Ask the ADHD Experts  Prescribing ADHD Medications

For ADHD patients, the risk for a suicide event is about 30% greater than for non-ADHD patients.  Among the ADHD patients who attempted or completed suicide,the risk was increased for those who had also been diagnosed with a mood disorder, conduct disorder, substance abuse or borderline personality.  This is not surprising; the most serious and complicated cases of ADHD are those that have the greatest risk for suicidal events.  

The effects of medication were less clear.   The risk for suicide events was greater for ADHD patients who had been treated with non-stimulant medication compared with those who had not been treated with non-stimulant medication.  A similar comparison showed no effect of stimulant medications. 

This first analysis suffers from the fact that the probability of receiving medication increases with the severity of the disorder.  To address this problem, the researchers limited the analyses to ADHD patients who had had some medication treatment and then compared suicidal risk between periods of medication treatment and periods of no medication treatment.  This analysis found no increased risk for suicide from non-stimulant medications and, more importantly, found that for patients treated with stimulants, the risk for suicide was lower when they were taking stimulant medications.  This protective effect of stimulant medication provides further evidence of the long-term effects of stimulant medications which have also been shown to lower the risks for traffic accidents, criminality, smoking and other substance use disorders.

Stephen_Faraone_PhD_ADHD_in_Adults

ADHD itself is associated with sleep difficulties, independent of ADHD medications. Thus, it is very important that sleep quality is assessed prior to treatment so that the changes due to treatment can be correctly inferred.

(Editor’s Note: See our Ask the ADHD Experts session on ADHD and Sleep.)

In clinical trials of stimulant ADHD medications, insomnia is typically noted a side effect of the medications. But most of these studies have used subjective patient or parent reports of sleep quality. A new meta analysis, reviews 9 studies of a total of 246 patients enrolled in randomized controlled trials of a stimulant medication.

Ask_the_ADHD_Experts_-_Prescribing_MedicationsTo be included, studies must have had an objective measure of sleep quality, either polysomnography or actigraphy. The analysis showed that stimulant medications led to a) a longer time to get to sleep; b) worse sleep efficiency and c) a shorter duration of sleep. Some of these sleep measures worsened with an increasing number of doses and a shorter time on medication.

Given the adverse effects that lack of sleep can have on cognition and behavior, these data provide further impetus for clinicians, parents and patients to monitor the effects of stimulant ADHD medication on sleep and to take appropriate action (e.g., dose reduction, change of medication) as warranted.

REFERENCES

J Am Acad Child Adolesc Psychiatry. 2009 Sep;48(9):894-908. doi: 10.1097/CHI.0b013e3181ac09c9.
Sleep in children with attention-deficit/hyperactivity disorder: meta-analysis of subjective and objective studies.
Cortese S1, Faraone SV, Konofal E, Lecendreux M.

Pediatrics. 2015 Dec;136(6):1144-53. doi: 10.1542/peds.2015-1708.
Stimulant Medications and Sleep for Youth With ADHD: A Meta-analysis.
Kidwell KM1, Van Dyk TR2, Lundahl A2, Nelson TD2.

Editor’s Note: We interviewed several leading ADHD experts on treating ADHD in primary care and acquired some very interesting insights into how clinicians can learn about and treat ADHD in their practices.

Anthony_L_Rostain_MD_MA_-_ADHD_in_AdultsAnthony Rostain, MD MA: Physicians are often afraid about prescribing stimulant medications because they’re not familiar with the diagnosis of ADHD and they’re not sure whether they’re legitimately correct in prescribing these medications. Let’s start first by examining ADHD as a diagnosis. It is a legitimate diagnosis.

There is a medical procedure for making the diagnosis that includes taking careful history, getting the patient to fill out scales, getting collateral information from important others who understand something about the patient’s behavior. In addition you have to gather developmental history and educational history. You have to be aware of all of the different facets of the patient’s functioning and understand that ADHD is impacting and impairing that individual.

Brendan Montano AIA jZJbzOBrendan Montano MD: With familiarity and use of stimulant medications in ADHD I know I became much more willing and able to use them. Also many pediatricians have no problem with stimulants and I feel that that will also occur when the primary care network begins to treat ADHD more vigorously, diagnose it and treat it. Our pediatric allies had been used to treating ADHD in childhood and they’d been familiarized and become comfortable with the use of stimulant medications. I believe the same thing will occur with our adult primary care providers. Familiarity and seeing the beneficial effect will give comfort to those who treat with stimulant medications. Remembering again there are some non-stimulants that are also quite effective. Now, it is important to be aware of the fact that stimulant medications can be diverted, they can be misused, they can be abused.

Stephen_Faraone_PhD_ADHD_in_Adults
Stephen Faraone, PhD:
And that’s a reasonable concern. However, today that concern is mitigated by several factors. First, we have new formulations of stimulants that are much less abusable than the immediate-release Ritalin many of you are used to. Second, there are now FDA-approved non-stimulant alternatives for ADHD. So you really do have a very large toolbox of therapies to use for adultswith ADHD.

Brendan Montano, MD: The more you become familiarized and screen for this illness, the more you become familiarized with treating the illness. So I became comfortable by seeing the beneficial effects and the outcomes which were otherwise not going to occur in my ADHD patients. The lack of training of primary care practitioners has created a shortage of treatment for adults with ADHD. We have methodological studies that prove there are 10 million undiagnosed adults with ADHD in the United States. I think the 10 million people who have this disorder really deserve for us to become familiarized not only with how to diagnose ADHD but how to treat it.

Anthony Rostain, MD: It’s important to keep in mind that if you follow sound clinical practice and document what you’re doing, including how you made the diagnosis of ADHD, that you informed the patient about treatment options and that you gave the patient all kinds of patient education materials to warn them about the danger of misusing the medication, then you’re following standard medical practice and you won’t be in any medical or legal difficulty.