Risk of Bias and Quality of Evidence for Treatment of ADHD With Stimulant Medication

Post-COVID-19 Yearly Pattern Changes and Gender Variations in Attention Deficit Hyperactivity Disorder Patients at an Urban Mental Health Clinic in Alabama, USA

Introduction The COVID-19 era has seen an increased trend in attention deficit hyperactivity disorder (ADHD) diagnoses. Historically, males have been diagnosed with ADHD more frequently than females during childhood. Studies have indicated a higher use of stimulant medications among male ADHD cases compared to females. This study examines ADHD cases from 2021 to 2023 to analyze yearly trends following the initial COVID-19 spike and explores gender and age differences between ADHD-positive and ADHD-negative cases. Methods This retrospective study was conducted using data from an urban outpatient mental health clinic in Alabama. Data were extracted from Electronic Health Records (EHR) for patients seen from January 1, 2021, to December 31, 2023. The Institutional Review Board (IRB) approved the study under the exempt research category. Data were analyzed using Microsoft Excel (Microsoft® Corp., Redmond, WA, USA) and the Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, IBM Corp., Version 26.0, Armonk, NY). Diagnoses were based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria, and clinical diagnoses and medication information were obtained from the EHR. Results The study included 1,422 patients, of whom 881 (62%) were diagnosed with ADHD. Females with ADHD had significantly higher comorbid conditions, such as major depressive disorder, generalized anxiety disorder, panic disorder, and post-traumatic stress disorder, compared to males with ADHD. Gender differences in ADHD diagnoses were seen over the years, though no significant age differences were observed. Conclusions The study indicates a sustained high rate of ADHD diagnoses even after the initial COVID-19 spike. Females showed a higher ADHD diagnoses compared to males, but stimulant medication use remained consistent across genders. No significant age differences were observed between males and females with ADHD. Further research is needed to explore the reasons behind these gender differences and to evaluate their implications.

Trends in Antipsychotic Use for Youth with Attention-deficit/Hyperactivity Disorder and Disruptive Behavior Disorders

PURPOSE

To examine trends in off-label antipsychotic use for youth with attention-deficit/hyperactivity disorder with and without a comorbid disruptive behavior disorder.

METHOD

This cross-sectional study of annual trends from 2007 through 2015 used the IQVIA PharMetrics® Plus for Academics data. We identified 165,794 commercially-insured youth 3-18 years-old who had a diagnosis of attention-deficit/hyperactivity disorder and classified them into subgroups with and without disruptive behavior disorders comorbidities. Antipsychotic use, with or without a stimulant, was the primary dependent outcome. Logistic regression estimated the odds of antipsychotic use associated with comorbid attention-deficit/hyperactivity disorder and disruptive behavior disorders, adjusting for age, sex, study year, and other psychotropic use.

RESULTS

Over 70% of the 165,794 youth with attention-deficit/hyperactivity disorder were 5-14 years-old and male, and 12% had disruptive behavior disorders. Antipsychotic prevalence, with or without a stimulant, was 4.4% in 2007 and 3.4% in 2015. Stimulants with antipsychotics increased significantly from 2007 to 2015 for females (19.5% to 28.7%) and youth 15-18 years-old (25.9% to 32.7%). Adjusting for age, sex, study year, and other psychotropic use, youth with a comorbid disruptive behavior had a 2.5 (95%CI: 2.3,2.7) higher likelihood of receiving an antipsychotic than youth with attention-deficit/hyperactivity disorder and no comorbidities.

CONCLUSIONS

Antipsychotic use was associated with comorbid disruptive behaviors in youth with attention-deficit/hyperactivity disorder. Off-label antipsychotic use has increased for females and older adolescents. This article is protected by copyright. All rights reserved.

Does Methylphenidate Work in Children and Adolescents with Attention Deficit Hyperactivity Disorder?

OBJECTIVE

Attention deficit hyperactivity disorder (ADHD) is a common psychiatric disorder diagnosed in increasing proportions of children and adolescents. The psychostimulant methylphenidate has been considered the first-line pharmacological treatment for children and adolescents with ADHD for more than 60 years. Considering recent publications on methylphenidate for ADHD, we here give an overview of its effects in children and adolescents with ADHD, elicited by a well-disputed Cochrane review and narratively synthesise the evidence in the field.

METHOD

We searched for systematic reviews and meta-analyses that investigated methylphenidate as an intervention for children and adolescence with ADHD compared with placebo or no treatment. We assessed the quality of the evidence using AMSTAR II.

RESULTS

We found 24 eligible systematic reviews and meta-analyses of which 11 were rated as high- quality evidence according to AMSTAR II. The evidence claiming that methylphenidate is beneficial in treating children and adolescents with ADHD was of very low certainty. The underreporting of adverse events in randomised clinical trials may impede an adequate depiction of the balance between benefits and harms.

CONCLUSIONS

It appears that there is uncertain evidence on group-level to support the claim that methylphenidate is beneficial in treating children and adolescents with ADHD. Future randomised clinical trials and systematic reviews should include individual participant data, which would allow us to assess intervention effects across modifiers, like age, sex, ADHD subtypes, comorbidities, and dose.

Methylphenidate for ADHD rejected from the WHO Essential Medicines List due to uncertainties in benefit-harm profile

Attention deficit hyperactivity disorder (ADHD) is a common psychiatric disorder with estimated global prevalence rates between 3% and 5% in children and 2.5% in adults, depending on the classification system used. The psychostimulant methylphenidate is one of the most frequently used medications for ADHD. In this analysis article we describe shortly the evidence in the field, an application for inclusion of methylphenidate on the WHO Model List of Essential Medicines, the comments raised to the application and the WHO Expert Committee's decision. The application of getting methylphenidate on the WHO list was overzealous in reporting potential benefits, without highlighting key uncertainties and harms. Decisions encompassing medicines candidate to the WHO Model List should not be based on speculation about potential benefits and should fully incorporate areas of uncertainties. Even though methylphenidate has been used for over 60 years, the evidence concerning the benefits of this medication in children, adolescents and adults with ADHD is uncertain. The decision of the committee was to not include methylphenidate in the WHO Model List of Essential Medicines 'due to uncertainties in the estimates of benefit, and concerns regarding the quality and limitations of the available evidence for both benefit and harm'.

Treating a Child With Mental Illness

Drug treatment of attention-deficit hyperactivity disorder (ADHD) with stimulants, such as methylphenidate, has been widespread across the developed countries and is also becoming common in adults. However, this seemingly effective treatment is not without controversy on the evidence that supports their use. In addition, disparities in the frequency of its use across the world are tremendous. Although stimulants are one of the standard therapies for ADHD, autism spectrum disorder (ASD) lacks such a drug treatment. Focusing on neurogenetic conditions with defined genetic abnormalities, which have ASD as a co-existing symptom, a search for a druggable target of ASD continues.