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      Use of drugs for ADHD among adults—a multinational study among 15.8 million adults in the Nordic countries

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          Abstract

          Purpose

          The use of ADHD drugs among adults is controversial and has until recently not been approved for use in adults in most countries. The aim was to investigate use of ADHD drugs (stimulants and atomoxetine) among the entire adult population in the Nordic countries.

          Methods

          We conducted a multinational population-based prescription register study based on the entire adult population in the five Nordic countries (Denmark, Finland, Iceland, Norway and Sweden). All users of ADHD drugs aged 18–64 years during 2008–2012 were included, which for 2012 comprised 76,896 drug users among 15.8 million adult inhabitants.

          Results

          Annual prevalence of drug use increased during the study period for both genders and all age groups. The overall prevalence increased from 2.4 to 5.3 per 1000 men and 1.8 to 4.4 per 1000 women. Incidence also increased, but to a lesser extent in the last part of the study period. Methylphenidate was used by 88 % of drug users. Treatment was discontinued within the first year by 21 % of new drug users. Among all users of ADHD drugs, 53 % of men and 64 % of women concurrently used other psychotropic drugs, most frequently antidepressants and hypnotics. Psychotropic co-medication increased with age and was more pronounced among women than men.

          Conclusions

          Use of ADHD drug among adults more than doubled over a 5-year period, and a majority were concurrently treated with other psychotropics. Adults constitute a substantial proportion of persons treated with ADHD drugs. Thus, evidence for long-term efficacy and safety in adults is urgently needed.

          Electronic supplementary material

          The online version of this article (doi:10.1007/s00228-016-2125-y) contains supplementary material, which is available to authorized users.

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          Most cited references30

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          The age-dependent decline of attention deficit hyperactivity disorder: a meta-analysis of follow-up studies.

          This study examined the persistence of attention deficit hyperactivity disorder (ADHD) into adulthood. We analyzed data from published follow-up studies of ADHD. To be included in the analysis, these additional studies had to meet the following criteria: the study included a control group and it was clear from the methods if the diagnosis of ADHD included subjects who did not meet full criteria but showed residual and impairing signs of the disorder. We used a meta-analysis regression model to separately assess the syndromatic and symptomatic persistence of ADHD. When we define only those meeting full criteria for ADHD as having 'persistent ADHD', the rate of persistence is low, approximately 15% at age 25 years. But when we include cases consistent with DSM-IV's definition of ADHD in partial remission, the rate of persistence is much higher, approximately 65%. Our results show that estimates of ADHD's persistence rely heavily on how one defines persistence. Yet, regardless of definition, our analyses show that evidence for ADHD lessens with age. More work is needed to determine if this reflects true remission of ADHD symptoms or is due to the developmental insensitivity of diagnostic criteria for the disorder.
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            Epidemiology of attention-deficit/hyperactivity disorder across the lifespan.

            Prevalence estimates of the attention-deficit hyperactivity disorder (ADHD) and the rate of persistence of symptoms across the lifespan are heterogeneous, raising questions about the validity of the diagnosis. This review aims to discuss potential reasons for variability in ADHD prevalence estimates and rates of symptom persistence, as well as to present ADHD prevalence rates during the lifespan. The best available estimates of ADHD prevalence are around 5.29% for children and adolescents and 4.4% in adulthood. Estimates of ADHD prevalence and rate of symptom persistence over time seem to be highly affected by methodological characteristics of the studies. The review of ADHD epidemiology highlights the need for standardizing study methodologies to make findings comparable. Even so, epidemiological cross-national data seem to support the validity of ADHD.
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              ADHD drugs and serious cardiovascular events in children and young adults.

              Adverse-event reports from North America have raised concern that the use of drugs for attention deficit-hyperactivity disorder (ADHD) increases the risk of serious cardiovascular events. We conducted a retrospective cohort study with automated data from four health plans (Tennessee Medicaid, Washington State Medicaid, Kaiser Permanente California, and OptumInsight Epidemiology), with 1,200,438 children and young adults between the ages of 2 and 24 years and 2,579,104 person-years of follow-up, including 373,667 person-years of current use of ADHD drugs. We identified serious cardiovascular events (sudden cardiac death, acute myocardial infarction, and stroke) from health-plan data and vital records, with end points validated by medical-record review. We estimated the relative risk of end points among current users, as compared with nonusers, with hazard ratios from Cox regression models. Cohort members had 81 serious cardiovascular events (3.1 per 100,000 person-years). Current users of ADHD drugs were not at increased risk for serious cardiovascular events (adjusted hazard ratio, 0.75; 95% confidence interval [CI], 0.31 to 1.85). Risk was not increased for any of the individual end points, or for current users as compared with former users (adjusted hazard ratio, 0.70; 95% CI, 0.29 to 1.72). Alternative analyses addressing several study assumptions also showed no significant association between the use of an ADHD drug and the risk of a study end point. This large study showed no evidence that current use of an ADHD drug was associated with an increased risk of serious cardiovascular events, although the upper limit of the 95% confidence interval indicated that a doubling of the risk could not be ruled out. However, the absolute magnitude of such an increased risk would be low. (Funded by the Agency for Healthcare Research and Quality and the Food and Drug Administration.).
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                Author and article information

                Contributors
                oystein.karlstad@fhi.no
                Journal
                Eur J Clin Pharmacol
                Eur. J. Clin. Pharmacol
                European Journal of Clinical Pharmacology
                Springer Berlin Heidelberg (Berlin/Heidelberg )
                0031-6970
                1432-1041
                1 September 2016
                1 September 2016
                2016
                : 72
                : 12
                : 1507-1514
                Affiliations
                [1 ]Department of Pharmacoepidemiology, Norwegian Institute of Public Health, P.O.box 4404 Nydalen, 0403 Oslo, Norway
                [2 ]Centre of Public Health Sciences, Faculty of Medicine, University of Iceland Reykjavik, Reykjavik, Iceland
                [3 ]Centre for Pharmacoepidemiology, Department of Medicine, Karolinska Institute, Stockholm, Sweden
                [4 ]Research Department, The Social Insurance Institution, Helsinki, Finland
                [5 ]Clinical Pharmacology, Department of Public Health, University of Southern Denmark, Odense, Denmark
                Author information
                http://orcid.org/0000-0003-1204-787X
                Article
                2125
                10.1007/s00228-016-2125-y
                5110707
                27586399
                0c5b944a-4adb-40c0-82f3-8b3aae85fcf2
                © The Author(s) 2016

                Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

                History
                : 25 April 2016
                : 25 August 2016
                Funding
                Funded by: the Norwegian Resource Centre for ADHD, Tourette syndrome and Narcolepsy
                Categories
                Pharmacoepidemiology and Prescription
                Custom metadata
                © Springer-Verlag Berlin Heidelberg 2016

                Pharmacology & Pharmaceutical medicine
                adhd,psychostimulants,adults,pharmacoepidemiology,nordic countries

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