ADHD in Substance Use Disorders : Prevalence and Pharmacotherapy

Substance use disorders (SUD) and Attention deficit /hyperactivity disorder (ADHD) are persistent and prevailing disorders that conjointly are associated with negative lifeevents and mental distress. The overall aim of this thesis was to examine the rate of ADHD in substance using populations and to investigate the feasibility and efficacy of methylphenidate pharmacotherapy for treatment of co-existing ADHD and SUD. The prevalence of ADHD was investigated in Studies I and II, which were cross-sectional investigations including two stages: screening and assessment. Study I included seven countries; France, Hungary, the Netherlands, Norway, Spain, Sweden, and Switzerland. Study II comprised incarcerated women in Swedish prisons. An initial screening was completed with WHO’s Adult ADHD Self-Rating Scale (ASRS). The assessment included Conners’ Adult ADHD interview for DSM-IV (CAADID) as a ‘gold standard’ for ADHD diagnosis. For differential diagnostics, the MINI Plus interview was used for mood disorders, antisocial personality disorder (ASP) and SUD, and SCID-II was used to assess borderline personality disorder (BPD). The results show that compared to the general population, the rate of ADHD is higher both in treatment-seeking substance users and in female prisoners (Study I and II). Studies III and IV were randomized, double-blind, placebo-controlled trials with parallel groups design investigating the safety and efficacy of methylphenidate (MPH) for treatment of ADHD in amphetamine dependent patients. Study III was a 12-week trial investigating 18-72mg/day MPH in treatment-seeking outpatients (men and women) with change in ADHD symptoms as the primary outcome measure. Study IV was a 24-week trial investigating 18-180 mg/day MPH in men recruited from medium security prisons. The participants started treatment within two weeks before release from prison and continued treatment in an outpatient clinic. The primary outcome measure in Study IV was relapse to illicit drug use. Results from Study III show that both treatment groups significantly improved their ADHD symptoms, but there were no significant differences between the groups in either ADHD or substance use outcome measures. In study IV, compared to placebo treatment, MPH treatment resulted in significantly more negative urine samples, improvement in ADHD symptoms, and better retention in treatment. Collectively, the findings from the epidemiological studies suggest that a significant number of individuals with SUD are also afflicted with ADHD. It is important that more attention is given to adult ADHD in addiction treatment centres and in criminal justice systems in order to address the clinical needs of this population. The results from the present clinical trials suggest that MPH given in structured settings may be safe to use in currently abstinent amphetamine dependent individuals with ADHD. A flexible dose range with a higher maximum dose improved ADHD symptoms, clinical condition and retention in treatment, and reduced the risk for relapse to illicit drug use in long-term drug dependent individuals

Emotional inferences by pragmatics

It has for long been taken for granted that, along the course of reading a text, world knowledge is often required in order to establish coherent links between sentences (McKoon & Ratcliff 1992, Iza & Ezquerro 2000). The content grasped from a text turns out to be strongly dependent upon the reader’s additional knowledge that allows a coherent interpretation of the text as a whole. The world knowledge directing the inference may be of distinctive nature. Gygax et al. (2007) showed that mental models related to human action may be of a perceptual nature and may include behavioral as well as emotional elements. Gygax (2010), however, showed the unspecific nature of emotional inferences and the prevalence of behavioral elements in readers' mental models of emotions. Inferences are made in both directions; emotional inferences based on behavior and vice versa. Harris & de Rosnay (2002) and Pons et al. (2003) proved that different linguistic skills –in particular lexicon, syntax and semantics are closely related to emotion understanding. Iza & Konstenius (2010) showed that additional knowledge about social norms affects the participants’ prediction about would be inferred as the behavioral or emotional outcome of a given social situation. Syntactic and lexical abilities are the best predictors of emotion understanding, but making inferences is the only significant predictor of the most complex components (reflective dimension) of emotion comprehension in normal children. Recently, Farina et al. (2011) showed in a study that the relation between pragmatics and emotional inferences may not be so straight forward. Children with High Functioning Autism (HFA) and Asperger Syndrome (AS) present similar diagnostic profiles, characterized by satisfactory cognitive development, good phonological, syntactic and semantic competences, but poor pragmatic skills and socio-emotional competencies. After training in pragmatics a descriptive analyses showed the whole group to display a deficit in emotion comprehension, but high levels of pragmatic competences. This indicates a further need to study the relationship between emotion and inference in normal subjects too. We also suggest that while behavioral elements may indeed be of perceptual nature and the inference between emotion and behavior less culturally dependent especially when concerned with basic emotions -the inference concerned with social norms may be more complex and require elaborative inference. We suggest that in further studies a distinction between basic emotions and non basic emotions, social settings and non-social settings should be made. The cognitive models concerned with social action may be of more complex nature, but with recognizable features on lexical and syntactic levels.Universidad de Málaga. Campus de Excelencia Internacional Andalucía Tech

Monimuotoinen nykykielitiede haastaa

Humanististen koulukuntakiistojen ytimessä oli viime vuosisadalla kiista ihmisen ja kielen suhteesta. Mutta mitä on ihmisen biologian ja yhteiskunnan vallankäytön välissä? Kommunikoiva, ajatteleva ja toisia huomioiva agentti kertoo monimenetelmäinen nykykielitiede

Alkusanat

Peer reviewe

Early developmental, temperamental and educational problems in 'substance use disorder' patients with and without ADHD: Does ADHD make a difference?

AbstractIntroductionThe prevalence of ADHD among patients with substance use disorder (SUD) is substantial. This study addressed the following research questions: Are early developmental, temperamental and educational problems overrepresented among SUD patients with ADHD compared to SUD patients without ADHD? Do this comorbid group receive early help for their ADHD, and are there signs of self-medicating with illicit central stimulants?MethodAn international, multi-centre cross-sectional study was carried out involving seven European countries, with 1205 patients in treatment for SUD. The mean age was 40years and 27% of the sample was female. All participants were interviewed with the Mini International Neuropsychiatric Interview Plus and the Conners' Adult ADHD Diagnostic Interview for DSM-IV.ResultsSUD patients with ADHD (n=196; 16.3% of the total sample) had a significantly slower infant development than SUD patients without ADHD (n=1,009; 83.4%), had greater problems controlling their temperament, and had lower educational attainment. Only 24 (12%) of the current ADHD positive patients had been diagnosed and treated during childhood and/or adolescence. Finally, SUD patients with ADHD were more likely to have central stimulants or cannabis as their primary substance of abuse, whereas alcohol use was more likely to be the primary substance of abuse in SUD patients without ADHD.ConclusionThe results emphasize the importance of early identification of ADHD and targeted interventions in the health and school system, as well as in the addiction field

Risk factors for borderline personality disorder in treatment seeking patients with a substance use disorder: An international multicenter study

Borderline personality disorder (BPD) and substance use disorders (SUDs) often co-occur, partly because they share risk factors. In this international multicenter study, risk factors for BPD were examined for SUD patients. In total, 1,205 patients were comprehensively examined by standardized interviews and questionnaires on psychiatric diagnosis and risk factors, and it was found that 1,033 (85.7%) had SUDs without BPD (SUD) and 172 (14.3%) had SUD with BPD (SUD + BPD). SUD + BPD patients were significantly younger, more often females and more often diagnosed with comorbid adult attention deficit/hyperactivity disorder. SUD + BPD patients did not differ from SUD patients on most risk factors typical for SUD such as maternal use of drugs during pregnancy or parents having any SUD. However, SUD + BPD patients did have a higher risk of having experienced emotional and physical abuse, neglect, or family violence in childhood compared to SUD patients, suggesting that child abuse and family violence are BPD-specific risk factors in patients with SUDs

Validity of the ADHD module of the Mini International Neuropsychiatric Interview PLUS for screening of adult ADHD in treatment seeking substance use disorder patients: ADHD screening with MINI-Plus

Az ADHD szűrési lehetőségei a Mini-plus mérőeszköz segítségéve

Adult attention deficit hyperactivity disorder symptom profiles and concurrent problems with alcohol and cannabis: Sex differences in a representative, population survey

Background: Adult attention deficit hyperactivity disorder (ADHD) shows a robust association with alcohol and cannabis misuse, and these relationships are expressed differently in males and females. Manifestation of specific ADHD symptom profiles, even in the absence of the full disorder, may also be related to problems with alcohol and cannabis, although these relationships have not been investigated in epidemiological studies. To address this question, we studied the sex-specific associations of ADHD symptomatology with problematic alcohol and cannabis use in a representative sample of adults aged 18 years and older residing in Ontario, Canada. Methods: Data were obtained from the Centre for Addiction and Mental Health Monitor, an ongoing cross-sectional telephone survey, between January 2011 and December 2013. Respondents (n = 5080) reported on current ADHD symptomatology, measured using the Adult ADHD Self-Report Version 1.1 Screener (ASRS-V1.1) and four additional items, and alcohol and cannabis use, which were measured using the Alcohol Use Disorders Identification Test (AUDIT) and the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST), respectively. Logistic regression analyses were conducted in men and women to test the association of each ADHD symptom cluster (hyperactivity, inattentiveness, impulsivity) with problematic alcohol and cannabis use. Results: After controlling for age, education, and comorbid internalizing and externalizing psychopathology, hyperactive symptoms were associated with problematic alcohol use in both men and women and with problematic cannabis use in men. Impulsive symptoms were independently associated with problematic cannabis use in men. By contrast, inattentive symptomatology predicted problems with alcohol and cannabis only in women. In all models, age was negatively associated with substance misuse and externalizing behavior was positively correlated and the strongest predictor of hazardous alcohol and cannabis use. Conclusions: ADHD symptom expression in adulthood is related to concurrent hazardous use of alcohol and cannabis. Distinctive ADHD symptom profiles may confer increased risk for substance misuse in a sex-specific manner

Interventions for drug-using offenders with co-occurring mental health problems

Background This review represents one from a family of three reviews focusing on interventions for drug‐using offenders. Many people under the care of the criminal justice system have co‐occurring mental health problems and drug misuse problems; it is important to identify the most effective treatments for this vulnerable population. Objectives To assess the effectiveness of interventions for drug‐using offenders with co‐occurring mental health problems in reducing criminal activity or drug use, or both. This review addresses the following questions. • Does any treatment for drug‐using offenders with co‐occurring mental health problems reduce drug use? • Does any treatment for drug‐using offenders with co‐occurring mental health problems reduce criminal activity? • Does the treatment setting (court, community, prison/secure establishment) affect intervention outcome(s)? • Does the type of treatment affect treatment outcome(s)? Search methods We searched 12 databases up to February 2019 and checked the reference lists of included studies. We contacted experts in the field for further information. Selection criteria We included randomised controlled trials designed to prevent relapse of drug use and/or criminal activity among drug‐using offenders with co‐occurring mental health problems. Data collection and analysis We used standard methodological procedures as expected by Cochrane . Main results We included 13 studies with a total of 2606 participants. Interventions were delivered in prison (eight studies; 61%), in court (two studies; 15%), in the community (two studies; 15%), or at a medium secure hospital (one study; 8%). Main sources of bias were unclear risk of selection bias and high risk of detection bias. Four studies compared a therapeutic community intervention versus (1) treatment as usual (two studies; 266 participants), providing moderate‐certainty evidence that participants who received the intervention were less likely to be involved in subsequent criminal activity (risk ratio (RR) 0.67, 95% confidence interval (CI) 0.53 to 0.84) or returned to prison (RR 0.40, 95% CI 0.24 to 0.67); (2) a cognitive‐behavioural therapy (one study; 314 participants), reporting no significant reduction in self‐reported drug use (RR 0.78, 95% CI 0.46 to 1.32), re‐arrest for any type of crime (RR 0.69, 95% CI 0.44 to 1.09), criminal activity (RR 0.74, 95% CI 0.52 to 1.05), or drug‐related crime (RR 0.87, 95% CI 0.56 to 1.36), yielding low‐certainty evidence; and (3) a waiting list control (one study; 478 participants), showing a significant reduction in return to prison for those people engaging in the therapeutic community (RR 0.60, 95% CI 0.46 to 0.79), providing moderate‐certainty evidence. One study (235 participants) compared a mental health treatment court with an assertive case management model versus treatment as usual, showing no significant reduction at 12 months' follow‐up on an Addictive Severity Index (ASI) self‐report of drug use (mean difference (MD) 0.00, 95% CI ‐0.03 to 0.03), conviction for a new crime (RR 1.05, 95% CI 0.90 to 1.22), or re‐incarceration to jail (RR 0.79, 95% CI 0.62 to 1.01), providing low‐certainty evidence. Four studies compared motivational interviewing/mindfulness and cognitive skills with relaxation therapy (one study), a waiting list control (one study), or treatment as usual (two studies). In comparison to relaxation training, one study reported narrative information on marijuana use at three‐month follow‐up assessment. Researchers reported a main effect < .007 with participants in the motivational interviewing group, showing fewer problems than participants in the relaxation training group, with moderate‐certainty evidence. In comparison to a waiting list control, one study reported no significant reduction in self‐reported drug use based on the ASI (MD ‐0.04, 95% CI ‐0.37 to 0.29) and on abstinence from drug use (RR 2.89, 95% CI 0.73 to 11.43), presenting low‐certainty evidence at six months (31 participants). In comparison to treatment as usual, two studies (with 40 participants) found no significant reduction in frequency of marijuana use at three months post release (MD ‐1.05, 95% CI ‐2.39 to 0.29) nor time to first arrest (MD 0.87, 95% CI ‐0.12 to 1.86), along with a small reduction in frequency of re‐arrest (MD ‐0.66, 95% CI ‐1.31 to ‐0.01) up to 36 months, yielding low‐certainty evidence; the other study with 80 participants found no significant reduction in positive drug screens at 12 months (MD ‐0.7, 95% CI ‐3.5 to 2.1), providing very low‐certainty evidence. Two studies reported on the use of multi‐systemic therapy involving juveniles and families versus treatment as usual and adolescent substance abuse therapy. In comparing treatment as usual, researchers found no significant reduction up to seven months in drug dependence on the Drug Use Disorders Identification Test (DUDIT) score (MD ‐0.22, 95% CI ‐2.51 to 2.07) nor in arrests (RR 0.97, 95% CI 0.70 to 1.36), providing low‐certainty evidence (156 participants). In comparison to an adolescent substance abuse therapy, one study (112 participants) found significant reduction in re‐arrests up to 24 months (MD 0.24, 95% CI 0.76 to 0.28), based on low‐certainty evidence. One study (38 participants) reported on the use of interpersonal psychotherapy in comparison to a psychoeducational intervention. Investigators found no significant reduction in self‐reported drug use at three months (RR 0.67, 95% CI 0.30 to 1.50), providing very low‐certainty evidence. The final study (29 participants) compared legal defence service and wrap‐around social work services versus legal defence service only and found no significant reductions in the number of new offences committed at 12 months (RR 0.64, 95% CI 0.07 to 6.01), yielding very low‐certainty evidence. Authors' conclusions Therapeutic community interventions and mental health treatment courts may help people to reduce subsequent drug use and/or criminal activity. For other interventions such as interpersonal psychotherapy, multi‐systemic therapy, legal defence wrap‐around services, and motivational interviewing, the evidence is more uncertain. Studies showed a high degree of variation, warranting a degree of caution in interpreting the magnitude of effect and the direction of benefit for treatment outcomes