|Year : 2021 | Volume
| Issue : 2 | Page : 94-100
Prevalence and profile of adult attention deficit hyperactive disorder in alcohol use disorder: An explorative study
Naveen Kumar Dhagudu1, Mayurnath Reddy1, Omesh Kumar2
1 Department of Psychiatry, ESIC Medical College and Hospital, Hyderabad, Telangana, India
2 Department of Psychiatry, Institute of Mental Health, Hyderabad, Telangana, India
|Date of Submission||30-Nov-2021|
|Date of Acceptance||02-Dec-2021|
|Date of Web Publication||12-Jan-2022|
Dr. Naveen Kumar Dhagudu
Department of Psychiatry, ESIC Medical College and Hospital, Hyderabad - 500 038, Telangana
Source of Support: None, Conflict of Interest: None
Objectives: To assess the prevalence of adult attention deficit hyperactive disorder (ADHD) in alcohol use disorder. To explore the attitude towards treatment of ADHD comorbidity among the people with alcohol use disorders. To explore the clinical profile of comorbid adult ADHD in alcohol use disorder.
Background: Adult attention deficit hyperactive disorder (ADHD) often under-diagnosed and under-treated among the people with alcohol use disorder (AUD). This current study was intended to assess the prevalence of adult ADHD in treatment-seeking patients with AUDs and its clinical predictors' profile and to explore the attitude of the individuals with adult ADHD toward its treatment.
Methodology: This was a cross-sectional study conducted in 200 consecutive treatment-seeking in and outpatient subjects with AUD. Participants were assessed their sociodemographic and clinical predictor profile details along with, questionnaires such as Maudsley Addiction Profile, Mini International Neuropsychiatric Interview 5.0, adult ADHD Rating Scale, and Clinical Institute of Alcohol Withdrawal-Ar Scale. Those positive for adult ADHD (ADHD+) were compared with those negative (ADHD−) on various clinical variables. Furthermore, the attitude toward treatment for ADHD among the ADHD+ subjects was assessed.
Results: Thirty-six participants (18%) screened positive and confirmed for adult ADHD. Less than one-fourth (n = 6, 16.7%) of participants were willing for any treatment, and majority (n = 16, 50%) were not sure to get the same. Participants with adult ADHD in AUD presented with earlier age of onset of alcohol use, more severity of alcohol use profile, and more.
Conclusions: About 18% prevalence of adult ADHD in treatment-seeking AUD highlighting the importance of its recognition. Furthermore, there is utmost need to sensitize about the treatment modalities for ADHD in participants with AUD to reduce the adverse outcomes of the same.
Keywords: Adult ADHD, alcohol use disorder, attitude towards ADHD treatment, outcomes, prevalence, profile
|How to cite this article:|
Dhagudu NK, Reddy M, Kumar O. Prevalence and profile of adult attention deficit hyperactive disorder in alcohol use disorder: An explorative study. Telangana J Psychiatry 2021;7:94-100
|How to cite this URL:|
Dhagudu NK, Reddy M, Kumar O. Prevalence and profile of adult attention deficit hyperactive disorder in alcohol use disorder: An explorative study. Telangana J Psychiatry [serial online] 2021 [cited 2023 Jun 5];7:94-100. Available from: https://tjpipstsb.org/text.asp?2021/7/2/94/335647
| Introduction|| |
Attention deficit hyperkinetic disorder (ADHD) is a common and serious concern among children., Whereas, in some symptoms of ADHD persist into adulthood and manifest primarily as inattention and impulsivity., The presence of symptoms of ADHD in adulthood is associated with persistence of impairments and greater frequency of occurrence of negative life events., In literature noted that ADHD has been associated with greater rates of occurrence of substance use disorders in adulthood. Consequently, individuals with substance use disorders seem to have higher rates of ADHD than the general population. Synthesis of literature through meta-analysis suggests that ADHD is children is associated with higher rates of nicotine use disorder, alcohol use disorder (AUD), cannabis use disorder, and cocaine use disorder, but not alcohol use.
AUD is having with chronic relapsing course and it affects globally, around 100.4 million individuals in 2016. AUD is having with chronic relapsing course and it is estimated that affects globally, around in100.4 million individuals. Consumption of alcohol in harmful way is accounted for 5.1% of the global burden of disease. The disorder is associated with considerable social, economic, and healthcare costs. Studies have found that patients with AUDs have high rates of adult ADHD. The studies from all over the world noted that adult ADHD has prevalence rates among inpatients about 5%–22%, whereas in outpatients about 4%–14%., Whereas in India, noted that 19% of ADHD prevalence in subjects with alcohol dependence. Another interventional prospective study from India revealed positive correlation between adult ADHD symptom severity with alcohol dependence syndrome (ADS) severity and as well found that methylphenidate intervention had reduction effect on ADHD symptoms severity and ADS severity. Yet another study from U. S. reported that treatment of ADHD had positive impact on the severity of craving and relapse to alcohol abuse correlated significantly with worsening of most ADHD symptoms among alcohol-dependent population. Thus, many studies have suggested that patients with alcohol dependence have high rates of ADHD.
Studies have tried to find out whether clinical features are different between patients with alcohol dependence with or without ADHD. It has been suggested that alcohol-dependent patients with ADHD have higher rates of psychiatric comorbidity than patients without ADHD. Apart from other substance dependence such as nicotine, affective, anxiety, and personality disorders were more likely to be present among patients with alcohol dependence having ADHD. The role of comorbidity plays a determining risk factor in the progression of alcohol use to dependence level in patients with ADHD., Patients with alcohol dependence having ADHD were more likely to have impulsivity and psychopathology and were more likely to have a pervasive executive deficits and earlier relapses than patients who did not had ADHD comorbidity. Thus, there seems to be many clinical parameters that differentiate patients with alcohol dependence who have ADHD and those without ADHD.
Treatment of patients with ADHD with comorbid substance use disorder is considered somewhat challenging, particularly with respect to the concerns about diversion of methylphenidate, a stimulant. The limited published evidence on this topic also makes recommendations difficult to be formulated. Yet, there is some evidence to suggest that ADHD symptoms in patients with alcohol dependence can be treated with medications. ADHD medications seem to have been prescribed to very lesser patients on treatment for alcohol dependence (suggesting a considerable treatment gap), and controlled release methylphenidate seems to be the most commonly prescribed medication. There could be concerns from patients' and physician perspectives that may influence the decision to treat ADHD in substance taking population.
Overall, ADHD still remains under-detected and under-treated in patients with substance use disorders. As of now, there are no studies from India which have reported rates of adult ADHD in severity domains of AUD population. Understanding the extent of the occurrence of ADHD in this population would be helpful in planning intervention/services for them. Adult ADHD is an impairing condition and addressing it additionally may be able to help the quality of life and outcomes of the patients. Thus, this study has been planned to assess the rates of occurrence of ADHD in patients with AUD, and to discern the clinical characteristics which differentiate those having and those not having comorbid ADHD. The study also attempts to enquire what kind of treatment options that they would prefer from the patients who are screened positive for ADHD.
| Methodology|| |
This was designed as an observational cross-sectional study. Study Universe was all patients who were seeking treatment for their AUD from a tertiary multispecialty medical college hospital in an urban setting. A convenient sampling technique was used for participant recruitment for the study. The consecutive patients who admitted to ED, Psychiatry and alcohol-related health seeking in their respective departments would be offered participation. Among the approached a total of around 200 participants selected over a year period from August 2020 to July 2021 and were included in the study after taking the informed consent. The inclusion criteria were: Age 18 years and above, both gender and meeting the criteria for diagnosis of AUD as per DSM 5. Exclusion criteria were as follows: participants unable to participate in the study to severe psychiatric or physical comorbidity (based on records and clinical assessment) that precludes interview-based assessments, Having features of intoxication or significant withdrawals (Clinical Institute Withdrawal Assessment– Alcohol revised score more than 10) that precludes assessments and who were expressing their refusal to give informed consent.
The data were collected from patients by the trained psychiatrist (ND), after taking informed consent and ensuring confidentiality. Initially, subject's basic sociodemographic details and substance use variables profile taken with semi-structured questionnaire from all. Participants were applied adult ADHD self–report scale (ASRS) after completion of withdrawal management and or the CIWA-Ar score being 9 or less for accuracy of reporting. Among the partcipants who screened positive with ASRS screen scale positive were underwent clinical interview for diagnostic ADHD confirmation using with DSM5 criterion by independent psychiatrist (MR/OK).
- Semi-structured questionnaire: For sociodemographic and clinical parameters including details of demographic information such as age, gender, occupation and employment status, educational status, marital status, current living arrangement, and residential status. Substance use details like duration of alcohol use, pattern, and presence of other substance dependence would have been recorded. Also, the diagnosis with regards to substance use disorders would record
- Maudsley addiction profile: This was a brief instrument to assess problems in four domains: Substance use, health risk behavior, physical and psychological health, and personal/social functioning. This questionnaire was helpful for the assessment of patients with drug or alcohol dependence. This instrument was in the public domain and is free to use for not-for-profit applications.
- MINI– Mini-International Neuropsychiatric Interview. 5.0: This is a structured instrument to ascertain various psychiatric disorders. It is a short structured diagnostic interview, developed jointly by multi-nation psychiatrists and clinicians. With an administration time of approximately 15 min, it was designed to meet the need for a short but accurate structured psychiatric interview. It's a clinician-administered interview which is divided into multiple sections, and the responses are in yes/no format. The instrument is free for use in nonfunded institutional-based research.
- Adult ADHD Self-Report Scale: This is a self-reported instrument to assess for the presence of adult ADHD. This brief questionnaire comprises 18 questions. The questionnaire has good specificity, fair sensitivity, and good diagnostic accuracy. The questionnaire is in the public domain
- Clinical Institute Withdrawal Assessment– Alcohol revised: This is a clinician-administered instrument for the assessment of the withdrawal symptoms of AUD. The questionnaire comprises 10 questions, and the scores range from 0 to 67 and with absent to minimal (0–9) mild to moderate (10–20), severe withdrawals categories (more than 20)
- Patients who are screened to have ADHD would be further asked a few questions about whether they think that they should take treatment for the symptoms of ADHD, and if yes what forms of treatment would be preferable (pharmacological or psychotherapeutic).
The data collected were entered into the Microsoft Excel program and analyzed in (IBM, SPSS statistics for Windows, Version 21.0, Armonk, NY). Appropriate parametric and nonparametric tests shall be applied based on the distribution of data. The outcomes of interest would include the occurrence/prevalence rate of ADHD in the sample population. Subsequently, the clinical variables of interest would compare between patients who screen positive for ADHD and those who screen negative for ADHD. The level of statistical significance shall be kept at P < 0.05 for all the tests.
Institutional Ethics Committee permission was taken for conducting the study (ESICMC/SNR/IEC-F0206/08-2020). All patient-related information had kept in lock and key or a digital device with password and would only use for report writing or publication to a scientific journal. Had taken measures for participation or nonparticipation in the study would not affect the usual treatment of the patients. Those screened positive for ADHD would informed to the treating team, which will take further decisions for the management of the patient.
| Results|| |
While in screening among the approached, 200 study subjects were selected as eligible based on selection criteria (n = 223). The reasons for exclusion are <18 years of age (n = 15), acute psychosis or severe distress state as such unable to give consistent responses (n = 6), and premature opt-out from the study completion without any proper reasons (n = 2).
The mean age of study participants of the person with AUD was 34.90 (standard deviation [SD] = 8.28). Majority were male, nearly half of them were divorced or separated. Furthermore, nearly half of them have lesser than primary level education. Study participants were predominantly belongs to Hindu religion and were having nuclear type of family [Table 1].
Findings of ADHD occurrence rate
Among the 200 treatment-seeking people with AUD had screened positive for attention deficit hyperactivity disorder was 18% (n = 36) with validated ASRS screening instrument. Whereas, the prevalence rates of adult ADHD in AUD represented in positive progression manner in DSM 5 severity dimensions.
Attitude toward the treatment of ADHD among the ADHD screened positive
Among the ADHD screened positive people with AUD, 1 in 6 only expressed their willingness to receive ADHD treatment and about half of were (n = 18) had not sure about to receive the same. Among those expressed willingness (n = 6) to receive treatment almost equally preferable for both pharmacotherapy and nonpharmacological psychotherapies. Interestingly, among those who had intent to receive pharmacotherapy, all were ready to buy (n = 3) [Table 2].
|Table 2: Prevalence of adult attention deficit hyperactivity disorder and attitude towards treatment|
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Comparative clinical profile of adult ADHD positive comorbidity among people with alcohol use disorder
The mean age of participant study subjects was lower for who screened positive for ADHD (ADHD+) when compared to those without ADHD (ADHD−) comorbidity, despite no significant difference in duration of alcohol use. Importantly, the significant difference found that lower mean age for the first exposure to alcohol in their alcohol use history and first to get physical or psychological problem exposed among ADHD+ group. Also, ADHD+ group subjects had significantly escalated to early morning use of alcohol in their course, the first admission requirement in earlier age than their counterpart. Similarly, higher quantity of alcohol consumption of last month presentation, higher withdrawal presentation, higher number of relapses while in the treatment period, and number of complicated withdrawals like delirium tremens also found as significant difference. Furthermore, on measuring addiction severity on measures such as physical health, anxiety, depression scores were higher and as well, higher proportion of days having conflict with spouse and with friends and not being fulfilled the social and familial responsibilities significantly among ADHD+ group than those individuals with ADHD− group [Table 3].
|Table 3: Alcohol use profile in subjects with and without attention deficit hyperactive disorder|
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| Discussion|| |
The current study objective was to know the prevalence rate of adult attention deficit hyperactivity disorder (ADHD) in treatment-seeking AUD population. This was found to be 18% by using with ASRS screening tool, which is consistent with previous literature., though this was further confirmed with using DSM 5 criteria. However, this magnitude was highlighting the importance for exploring the phenomenon of comorbidity of ADHD in people with AUD. Hence, we did this study with the objectives of comparison of clinical predictors profile between ADHD positive and ADHD negative. Furthermore, we did explore the attitude toward to treatment for ADHD. It was intended to know willingness to receive the treatment, preferable form of treatment, and readiness to buy the treatment.
In literature, the comorbidity of ADHD phenomenon in people with AUD is under-recognized one., It explained that in often complication with overlapping with impulsivity and or hyperactivity by alcohol-induced withdrawals or craving.,, hence we did assessment of ADHD phenomenon after the subsidence of severe withdrawals to a minimal state (CIWA-Ar score <8) after the treatment and then interviewing with family members about the longitudinal course of the person with AUD for the differential variables recognition. Further, those having acute mood or psychotic illness were excluded from the study. Furthermore, adult ADHD phenomenon as a comorbidity in AUD was often undertreated in the literature,, which mimics with our findings that only 1 in 6 people with AUD positive for ADHD expresses their willingness to receive any treatment. Highlighting here was all were ready to buy medicine among chosen for pharmacotherapy.
We found that ADHD positive or comorbid with people with AUD were 7 years younger compared to ADHD negative people with AUD. Furthermore, the time of first exposure having to alcohol and first to get physical or psychological harm happened in younger age in ADHD comorbid AUD subjects group than their counterpart. This was proven as similar to previous studies.,, The disease progression markers or some epi-phenotypes for AUD course like age at withdrawal occurrence, the quantity of consumption of alcohol per day, age of initiation of early morning drinking as eye opener, at age first inpatient service required for recovery from alcohol-related effects, duration of maximum abstinence period difference noted as significant and reflected these all as faster progression and severity of alcoholism among ADHD comorbid people with AUD than without this comorbidity. The findings from this study are similar to earlier studies in India and from other parts of the world.,,
Comorbidity of adult ADHD and AUD profoundly influence the disease course and outcome adversely, possibly mediating through common higher impulsivity and executive dysfunction. Similarly, typology of people with AUD described in the earlier classification of alcoholism by Babor's as in type B mimics with subjects with ADHD comorbidity in AUD population, who were also had the faster course of severity and reflected as early-onset, a more rapid onset of complications, more severe symptoms, and poorer prognosis. The current study findings support for further intensive, prospective interventions and innovative modalities of management for this comorbid ADHD with the AUD population.
Furthermore, as per management concern, this comorbid ADHD in people with AUD was a challenging one. This underlying comorbid pathology makes them relapse earlier while in treatment and dropout from the AUD treatment. Hence, comorbid ADHD group of AUD has lesser abstinent period compared to those without ADHD even after taking treatment for their AUD. Similarly, earlier studies reported that patients with ADHD had lower remission rates and longer duration of substance use.,
To our knowledge, this study represents the largest exploration of the association between with and without comorbid ADHD groups among AUD in India. Specifically in this study mapping of prevalence became significant here because identification was done not only with well-validated self-reported screening instruments also backing with clinical interviews using with DSM 5 criteria. This study population can be considered as heterogeneous among the treatment-seeking AUDs such as the study subjects belongs to both inpatient and outpatient settings and as well to all severity categories, from mild to severe, hence generalizability to the extent possible to all treatment-seeking AUD population. Importantly, our study sample also had female subjects which analogous to multispecialty general hospital setup AUD patient profile.
The current study was a cross-sectional design and here adult ADHD diagnosis was confirmed by clinical interview method using DSM 5, and no structured diagnostic instruments were used for making adult ADHD diagnosis. The presence of childhood ADHD symptoms was not assessed. However, our modest sample size might have been underpowered to run the tests of association involving multiple independent variables. In addition, we did not look into important close constructs such as impulsivity. Furthermore, this study includes the treatment-seeking participants with AUD only, majority were belongs to not seeking treatment in public or community hence, our findings cannot claim generalizability to all.
| Conclusions|| |
Our present study confirms high ADHD comorbidity in subjects with AUD and majorities were not sure to receive any form of treatment for the same. Among those who show their willingness were ready to buy approved medicines. Other important correlates for comorbid adult ADHD had earlier onset of alcohol use, younger at presentation, having had faster progression and have a more severe course with more relapses while in treatment. Henceforth, all patients should be evaluated for ADHD and interventions should be initiated for the comorbid ADHD along with treatment for AUDs. Recommending for studies of interventional prospective designs nature for this ADHD comorbidity in AUD subjects, in a larger sample and as well in different settings like the community to assess the impact of the reduction in adverse outcomes along with benefits of the same.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]