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Substance abuse disguised as ADHD?
Response to Dr. Berg
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John E. Berg, Psychiatrist Lovisenberg Diakonal Hospital
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john{at}pong.no John E. Berg
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Adult attention-deficit hyperactivity disorder ADHD is a rather novel disease in adults. It has drawn increasing attention, and momentarily there is no deficit of studies of ADHD in adults (Fayyad, De Graaf, Kessler, et al, 2007). Several studies have shown a considerable risk of cooccuring substance abuse in adults given the ADHD diagnosis(Wilson, 2007) (Aanonsen, 1999). ADHD symptoms seem to hamper success in methadone miantenance treatment (Kolpe & Carlson, 2007). Table 5 in the study of Fayyad etal indicates that adult ADHD occur first in patients with a co-occurring substance abuse disorder in 99% of cases. This observation is not commented in the discussion part of the paper. Respondents were classified retrospectively as having met full ADHD criteria in childhood. To ascertain the presence of ADHD at adult age the respondents were asked a single question only, whether they continued to have problems with attention or hyperactivity. In my country we have an impression that persons with substance abuse tend to ask for a diagnosis of ADHD, as this may give better treatment service within the psychiatric care system than presenting oneself as a ”mere” drug addict. Also when little documentation of ADHD problems in childhood are found. The finding of Fayyad etal of higher prevalences in high-income countries, with purportedly better treatment service for ADHD, may be an indication of common presented symptoms in both substance abuse and ADHD disorders. May the authors have observed substance abuse related symptoms and behaviour, and not ADHD related ones? Aanonsen, N. O. (1999) Sentralstimulerende legemidler og misbrukspotensial ved hyperkinetisk forstyrrelse. Tidsskr Nor Lćgeforen, 119, 4040-4042. Fayyad, J., De Graaf, R., Kessler, R. C., et al (2007) Cross-national prevalence and correlates of adult attention-deficit hyperactivity disorder. Br J Psychiatr, 190, 402-409. Kolpe, M. & Carlson, G. (2007) Influence of attention- deficit/hpyeractivity disorder symptoms on methadone treatment outcome. Am J Addict, 16, 46-48. Wilson, J. (2007) 2007. Am J Addict, 16, 5-11. |
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Ronald C. Kessler, Professor Harvard Medical School, John Fayyad, Ronald Kessler, Jordi Alonso, Koen Demyttenaere, Josep Maria Haro, Elie G. Karam, Carmen Lara, Jean-Pierre LĂ©pine, and Alan M. Zaslavsky.
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kessler{at}hcp.med.harvard.edu Ronald C. Kessler, et al.
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Dr. Berg raises the possibility that respondents in our surveys who reported adult persistence of ADHD might actually have had symptoms caused by some other disorders, such as alcoholism, that are more stigmatizing and less likely to be treated than ADHD. Such respondents might consciously have provided incorrect information in an effort to avoid stigma and to increase their chances of receiving treatment. Dr. Berg states that such machinations occur in his country. This is an important point in light of the powerful stigma associated with mental disorders and the fact that some health-care systems discriminate against certain diagnoses. Mental health professionals need to rally their efforts in order to raise awareness and address these problems. That said, it strikes us as implausible that our findings are importantly affected by the sort of bias proposed by Dr. Berg for the following reasons: First, the World Mental Health (WMH) surveys are community epidemiological surveys in which no treatment is provided. Second, in a number of the WMH participating countries, ADHD is not commonly recognized as an illness, making it unlikely that community respondents would have the sophistication to seek out this diagnosis. Third, we carried out in-depth clinical reappraisal interviews with a probability sub-sample of respondents who reported adult persistence of ADHD. We excluded respondents from diagnosis if concerns existed that another diagnosis might be primary. While it is possible that some respondents were so familiar with ADHD that they tricked our experienced clinical interviewers, we consider it unlikely that this was a widespread occurrence. Fourth, treatment seeking was low in most WMH surveys. When it occurred, the reason for seeking treatment was not ADHD but rather a comorbid disorder. Irrespective of whether the type of bias Dr Berg suggested exists in epidemiologic surveys, our results imply that clinicians should look more seriously for ADHD in their adult patients than they have before. As more physicians screen for ADHD among adults presenting for treatment of other psychiatric disorders, the extent to which untreated adult ADHD exists among help-seekers will become apparent. Declaration of interest: Ronald Kessler has been a consultant for Astra Zeneca, BristolMyersSquibb, Eli Lilly and Co, GlaxoSmithKline, Pfizer, Sanofi- Aventis, and Wyeth and has had research support for his epidemiological studies from BristolMyersSquibb, Eli Lilly and Company, Ortho-McNeil, Pfizer, and the Pfizer Foundation. Koen Demyttenaere – Occasional consultancy or speaker fees from Boehringer-Ingelheim, Cyberonics, Glaxo-Smith-Kline, Eli Lilly, Lundbeck, and Wyeth The remaining authors report no declaration of interest. Corresponding author: Ronald C. Kessler Professor Department of Health Care Policy Harvard Medical School 180 Longwood Avenue Boston, MA 02115 Tel. 617-432-3587 Fax 617-432-3588 kessler@hcp.med.harvard.edu John Fayyad, MD Institute for Development, Research, Advocacy and Applied Care (IDRAAC), Dept. of Psychiatry and Clinical Psychology, St. George Hospital University Medical Center and Faculty of Medicine, Balamand University, Beirut, Lebanon St. George Hospital PO Box 166378 Beirut-Achrafieh 1100-2807 Lebanon Ronald Kessler, PhD (Corresponding author) Department of Health Care Policy, Harvard Medical School, Boston, MA, USA Jordi Alonso, MD, PhD Health Services Research Unit, Institut Municipal d´Investigació Mèdica (IMIM), Barcelona, Spain Headm Health Services Research Unit PRBB, Doctor Aiguader, 88 08003 BARCELONA Koen Demyttenaere, MD, PhD Department of Neurosciences and Psychiatry, University Hospitals Gasthuisberg, Belgium Herestraat 49 3000 Leuven Belgium Josep Maria Haro, MD, PhD Sant Joan de Déu-SSM, Fundació Sant Joan de Déu, Sant Boi de Llobregat, Barcelona, Spain Dr. Antoni Pujades, 42 08830 Sant Boi de L. (Barcelona) Spain Elie G. Karam, MD Institute for Development, Research, Advocacy and Applied Care (IDRAAC), Dept. of Psychiatry and Clinical Psychology, St. George Hospital University Medical Center and Faculty of Medicine, Balamand University, Beirut, Lebanon P.O. Box 166378 Youssef Sursock Street Beirut-Achrafieh 1100-2807 Lebanon Carmen Lara, MD, PhD Instituto Nacional de Psiquiatria, Universidad Autonoma Metropolitana, Mexico City, Mexico Calzada Mexico Xochimilco No. 101-Col. San Lorenzo Huipulco 14370 Mexico D.F. C.P. Mexico Jean-Pierre Lépine, MD Hospital Fernand Widal, Paris, France 200 rue de Fauborg Saint Denis Cedex 10 75475 Paris France Alan M. Zaslavsky,PhD Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue Boston, MA 02115 Boston, MA, USA |
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