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Cross-national prevalence and correlates of adult attention-deficit hyperactivity disorder

  • John Fayyad (a1), Ron De Graaf (a2), Ronald Kessler (a3), Jordi Alonso (a4), Matthias Angermeyer (a5), Koen Demyttenaere (a6), Giovanni De Girolamo (a7), Josep Maria Haro (a8), Elie G. Karam (a9), Carmen Lara (a10), Jean-Pierre Lépine (a11), Johan Ormel (a12), José Posada-Villa (a13), Alan M. Zaslavsky (a3) and Robert Jin (a3)...
Abstract
Background

Little is known about the epidemiology of adult attention-deficit hyperactivity disorder (ADHD).

Aims

To estimate the prevalence and correlates of DSM-IV adult ADHD in the World Health Organization World Mental Health Survey Initiative.

Method

An ADHD screen was administered to respondents aged 18–44 years in ten countries in the Americas, Europe and the Middle East (n=11422). Masked clinical reappraisal interviews were administered to 154 US respondents to calibrate the screen. Multiple imputation was used to estimate prevalence and correlates based on the assumption of cross-national calibration comparability.

Results

Estimates of ADHD prevalence averaged 3.4% (range 1.2–7.3%), with lower prevalence in lower-income countries (1.9%) compared with higher-income countries (4.2%). Adult ADHD often co-occurs with other DSM-IV disorders and is associated with considerable role disability. Few cases are treated for ADHD, but in many cases treatment is given for comorbid disorders.

Conclusions

Adult ADHD should be considered more seriously in future epidemiological and clinical studies than is currently the case.

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Copyright
Corresponding author
Dr John Fayyad, Department of Psychiatry and Clinical Psychology, St George Hospital University Medical Centre, PO Box 166378, Beirut-Achrafieh 1100–2807, Lebanon. Tel: +961 (1)58 3583; fax: +961 (1)58 7190; email: jfayyad@idraac.org
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Declaration of interest

None. Funding detailed in Acknowledgements.

Footnotes
References
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Cross-national prevalence and correlates of adult attention-deficit hyperactivity disorder

  • John Fayyad (a1), Ron De Graaf (a2), Ronald Kessler (a3), Jordi Alonso (a4), Matthias Angermeyer (a5), Koen Demyttenaere (a6), Giovanni De Girolamo (a7), Josep Maria Haro (a8), Elie G. Karam (a9), Carmen Lara (a10), Jean-Pierre Lépine (a11), Johan Ormel (a12), José Posada-Villa (a13), Alan M. Zaslavsky (a3) and Robert Jin (a3)...
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eLetters

Response to Dr. Berg

Ronald C. Kessler, Professor
15 August 2007

Dr. Berg raises the possibility that respondents in our surveys who reported adult persistence of ADHD might actually have had symptoms causedby 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 andthe 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 itoccurred, 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. KesslerProfessorDepartment of Health Care PolicyHarvard Medical School180 Longwood AvenueBoston, MA 02115Tel. 617-432-3587Fax 617-432-3588kessler@hcp.med.harvard.edu

John Fayyad, MDInstitute 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, LebanonSt. George HospitalPO Box 166378Beirut-Achrafieh 1100-2807Lebanon

Ronald Kessler, PhD (Corresponding author)Department of Health Care Policy, Harvard Medical School, Boston, MA, USA

Jordi Alonso, MD, PhDHealth Services Research Unit, Institut Municipal d´Investigació Mèdica(IMIM), Barcelona, SpainHeadm Health Services Research UnitPRBB, Doctor Aiguader, 8808003 BARCELONA

Koen Demyttenaere, MD, PhDDepartment of Neurosciences and Psychiatry, University Hospitals Gasthuisberg, BelgiumHerestraat 493000 LeuvenBelgium

Josep Maria Haro, MD, PhDSant Joan de Déu-SSM, Fundació Sant Joan de Déu, Sant Boi de Llobregat,Barcelona, SpainDr. Antoni Pujades, 4208830 Sant Boi de L. (Barcelona)Spain

Elie G. Karam, MDInstitute 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, LebanonP.O. Box 166378Youssef Sursock StreetBeirut-Achrafieh 1100-2807Lebanon

Carmen Lara, MD, PhDInstituto Nacional de Psiquiatria, Universidad Autonoma Metropolitana, Mexico City, MexicoCalzada Mexico Xochimilco No. 101-Col. San Lorenzo Huipulco14370 Mexico D.F. C.P.Mexico

Jean-Pierre Lépine, MDHospital Fernand Widal, Paris, France200 rue de Fauborg Saint DenisCedex 1075475 ParisFrance

Alan M. Zaslavsky,PhDDepartment of Health Care Policy, Harvard Medical School, 180 Longwood AvenueBoston, MA 02115Boston, MA, USA
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Conflict of interest: None Declared

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Substance abuse disguised as ADHD?

John E. Berg, Psychiatrist
05 July 2007

Adult attention-deficit hyperactivity disorder ADHD is a rather noveldisease 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 indicatesthat 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 tendto ask for a diagnosis of ADHD, as this may give better treatment servicewithin 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-incomecountries, 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 Lægeforen, 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. AmJ Addict, 16, 46-48.Wilson, J. (2007) 2007. Am J Addict, 16, 5-11.
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