Attention-Deficit/Hyperactivity Disorder and Major Depressive Disorder: Evidence From Multiple Genetically Informed Designs

Definition of Response in Randomized Controlled Trials of Medications for Attention-Deficit/Hyperactivity Disorder Across the Lifespan: A Systematic Review

Objectives: Randomized controlled trials (RCTs) are the gold standard for evaluating medication efficacy. The absence of a universal definition of treatment response, based on the degree of symptom improvement measured by standardized rating scales in the field of attention-deficit/hyperactivity disorder (ADHD), makes it difficult to compare treatment outcomes across RCTs. Here, we aimed to assess to what extent and how "treatment response" is defined across RCTs of ADHD medications. Methods: We identified eligible RCTs via the MED-ADHD database (https://med-adhd.org/), which compiles RCTs evaluating the efficacy and safety of pharmacological treatments for children, adolescents, and adults with ADHD, based on a comprehensive search in multiple electronic databases, including PubMed, BIOSIS Previews, CINAHL, the Cochrane Central Registry of Controlled Trials, and EMBASE, up to 17 January 2025, alongside additional unpublished information gathered from manufacturers/study authors. Results: Out of 167 RCTs in MED-ADHD, 88 defined treatment response based on reductions in ADHD core symptom severity using rating scale scores. The most frequently used threshold was a ≥30% reduction in attention-deficit/hyperactivity disorder (ADHD-RS) scores, with other RCTs using ≥25%, ≥40%, or ≥50%. In addition, RCTs applied similar cutoff values to alternative scales, including Conner's Adult ADHD Rating Scale, SNAP-IV, Adult ADHD Investigator Rating Scale, and Wender-Reimherr Adult Attention Deficit Disorder Scale. However, 79 studies did not specify any response threshold. Conclusion: Our review underscores and quantitatively defines the inconsistency in the definition of treatment response across ADHD medication trials, highlighting the urgent need for the field to reach a consensus on the use of a standardized definition of "treatment response" for each rating scale, based on the percentage reduction in ADHD core symptom severity.

Study Preregistration: Clinical and Cognitive Mediators Underlying Subsequent Depression in Individuals With Attention-Deficit/Hyperactivity Disorder: A Developmental Approach

Individuals with attention-deficit/hyperactivity disorder (ADHD) are about 5.5 times more likely to develop depression,1 and this comorbidity is associated with greater impairment than either disorder alone. Although there is evidence that ADHD may play a causal role in the development of depression,2,3 the underlying mechanisms remain poorly understood. Several clinical and cognitive mechanisms have been proposed: (1) clinical antecedents of depression, such as irritability and anxiety, often observed in individuals with 4,5; (2) cognitive-affective functions (response inhibition, working memory, sustained attention, and emotion recognition) impaired in individuals with ADHD and, to a lesser extent, in depressed individuals6,7; or (3) negative thought patterns underlying vulnerability to depression also observed in individuals with ADHD (external locus of control and negative cognitive styles).8 Nevertheless, few longitudinal studies have tested these as potential mediators between ADHD and subsequent depression. Existing studies are primarily cross-sectional, limited by small sample sizes, and have not examined developmental stage-specific effects. Therefore, we will explore the mediating role of clinical, cognitive-affective, and negative thought patterns, and whether their role varies by developmental stage and sex. We will examine all mediators simultaneously, the relative contribution of 3 categories of mediators, and the associations between ADHD and each hypothesized mediator/factor. We hypothesize the following: (1) ADHD will be more strongly associated with irritability and emotion recognition in childhood than in adolescence and young adulthood; (2) the association between ADHD and anxiety will be consistent across development; and (3) ADHD will be more strongly associated with response inhibition, working memory, sustained attention, external locus of control, and negative cognitive style in adolescence and young adulthood compared to childhood.

Comorbidity of attention deficit hyperactivity disorder in young adults who had major depressive disorder

BACKGROUND

The comorbidity of Major Depressive Disorder (MDD) and Attention Deficit Hyperactivity Disorder (ADHD) in adults is well recognized. The role of ADHD in the etiology of MDD, as well as the overlap of genetic and environmental factors between these two disorders, is an area of research. ADHD symptoms are considered risk factors for MDD.

OBJECTIVES

The study aimed to examine the relationship between MDD in young adults with history of ADHD.

DESIGN

Retrospective and observational study.

SETTINGS

Outpatient clinic of a tertiary hospital.

PATIENTS AND METHODS

Data of young adults diagnosed with MDD, aged 18-25 years and seen between January 2017 and May 2023, were included. Individuals with comorbidities other than ADHD in adulthood were excluded from the study. The sociodemographic and clinical data of a total of 489 cases, as well as data on childhood psychiatric referrals, diagnoses, and treatment histories, were retrospectively examined.

MAIN OUTCOME MEASURES

ADHD diagnosis history and clinical impact in adults diagnosed with MDD.

SAMPLE SIZE

489.

RESULTS

A total of 489 cases (68.9% female) with a mean age of 21.14 years were included in the study. It was determined that 8% of the cases had ADHD in adulthood, 13.3% in childhood, and 31.9% had at least one mental health diagnosis during childhood. The rate of ADHD diagnosis was significantly higher in males than females in both adulthood and childhood. Additionally, the age of diagnosis of MDD was lower in individuals with ADHD diagnosis and/or those who have discontinued ADHD treatment.

CONCLUSIONS

In young adults diagnosed with MDD, the comorbidity of ADHD should also be considered. It is important to acknowledge that ADHD is not just a childhood disorder but a lifelong disorder due to its negative consequences, and to develop appropriate strategies in this regard.

LIMITATİONS

Retrospective observational design and the single-center setting, which may affect the generalizability of the findings.

Evaluating ADHD medication trial representativeness: a Swedish population-based study comparing hypothetically trial-eligible and trial-ineligible individuals

BACKGROUND

Randomised controlled trials (RCTs) evaluating ADHD medications often use strict eligibility criteria, potentially limiting generalisability to patients in real-world clinical settings. We aimed to identify the proportion of individuals with ADHD who would be ineligible for medication RCTs and evaluate differences in treatment patterns and clinical and functional outcomes between RCT-eligible and RCT-ineligible individuals.

METHODS

We used multiple Swedish national registries to identify individuals with ADHD, aged at least 4 years at the age of diagnosis, initiating pharmacological treatment between Jan 1, 2007, and Dec 31, 2019, with follow-up up to Dec 31, 2020. Hypothetical RCT ineligibility was established using exclusion criteria from the international MED-ADHD dataset, including 164 RCTs of ADHD medications. Cox models evaluated differences in medication switching and discontinuation within 1 year between eligible and ineligible individuals. Quasi-Poisson models compared eligible and ineligible individuals on rates of psychiatric hospitalisations, injuries or accidents, and substance use disorder within 1 year of initiating ADHD medications. People with lived experience of ADHD were not involved in the research and writing process.

FINDINGS

Of 189 699 individuals included in the study cohort (112 153 men and boys [59%] and 77 546 women and girls [41%]; mean age 21·52 years [SD 12·83; range 4-68]) initiating ADHD medication, 53% (76 477 [74%] of 103 023 adults [aged >17 years], 12 658 [35%] of 35 681 adolescents [aged 13-17 years], and 10 643 [21%] of 50 995 children [aged <13 years]) would have been ineligible for RCT participation. Ethnicity data were not available. Ineligible individuals had a higher likelihood of treatment switching (hazard ratio 1·14, 95% CI 1·12-1·16) and a decreased likelihood of medication discontinuation (0·96, 0·94-0·98) compared with eligible individuals. Individuals ineligible for RCTs had significantly higher rates of psychiatric hospitalisations (ncidence rate ratio 9·68, 95% CI 9·57-9·78) and specialist care visits related to substance use disorder (14·78, 14·64-14·91), depression (6·00, 5·94-6·06), and anxiety (11·63, 11·56-11·69).

INTERPRETATION

Individuals ineligible for ADHD medication trials face higher risks of adverse outcomes. This study provides the first empirical evidence for the limited generalisability of ADHD RCTs to real-world clinical populations, by applying eligibility criteria extracted from a comprehensive dataset of RCTs to a large real-world cohort. Triangulating evidence from RCTs and real-world studies is crucial to inform rigorous evidence-based treatment guidelines.

FUNDING

National Institute of Healthcare and Research, European Union's Horizon 2020, and Swedish Research Council.

Effects of ADHD and ADHD medications on depression and anxiety in children and adolescents: A systematic review and meta-analysis

This systematic review and meta-analysis aimed to comprehensively assess the effects of attention-deficit/hyperactivity disorder (ADHD) and ADHD medications on the risk of depression and anxiety in children and adolescents. A comprehensive search of PubMed, Embase, Cochrane Library, and Web of Science was conducted up to January 30, 2024. The outcomes were depression and anxiety. Subgroup analysis was performed according to outcome population as youth onset, sex and duration of medication. Sensitivity analysis and publication bias assessment were also performed. Thirty-three studies were included. The children and adolescents with ADHD had a significantly higher risk of depressive disorder than those without ADHD [pooled relative risk (RR) = 2.27, 95% confidence interval (CI) = 1.57-3.29, P < 0.001]. The children and adolescents with ADHD were at a higher risk of major depressive disorder than those without ADHD (pooled RR = 2.20, 95%CI = 1.47-3.29, P = 0.002). The children and adolescents with ADHD had an increased risk of specific phobia versus those without ADHD (pooled RR = 1.68, 95%CI = 1.16-2.44, P = 0.006). The risk of social phobia in the ADHD group was higher than that in the non-ADHD group (pooled RR = 1.71, 95%CI = 1.13-2.61, P = 0.012). The children and adolescents with ADHD were at an elevated risk of agoraphobia compared with those without ADHD (pooled RR = 4.99, 95%CI = 1.51-16.56, P = 0.009). Children and adolescents with stimulant medications had a significantly lower risk of depression than those without stimulant medications (pooled RR = 0.80, 95%CI = 0.72-0.89, P < 0.001). In conclusion, children and adolescents with ADHD had higher risks of depressive disorder, major depressive disorder, specific phobia, social phobia, and agoraphobia than those without ADHD. Stimulant medications for ADHD were associated with a reduced risk for depression.

The risk of attention deficit hyperactivity disorder symptoms in offspring of mothers with perinatal depression: A systematic review and meta-analysis

BACKGROUND

The existing epidemiological evidence on the link between maternal depression and the risk of attention deficit and hyperactivity disorder (ADHD) symptoms in children lacks consistency. This systematic review and meta-analysis aimed to comprehensively synthesise the existing evidence on the relationship between maternal depression during the antenatal and postnatal periods and the risk of ADHD symptoms in offspring.

METHODS

We systematically searched PubMed, Medline, Embase, Scopus, CINAHL, and PsychINFO to identify relevant articles. Random-effects meta-analysis models were employed to estimate the pooled odds ratio (OR) along with 95 % confidence intervals (CI). Statistical heterogeneity was assessed using Cochrane's Q-test and I2-test. Subgroup analysis was conducted to explore potential sources of variation within the included studies. Publication bias was assessed using a funnel plot and Egger's test for regression asymmetry.

RESULTS

Twenty-one observational studies, comprising 796,157 mother-offspring pairs, were included in the final analysis. Our meta-analysis found a 67 % (OR = 1.67, 95 % CI = 1.35-2.00) and a 53 % (OR = 1.53, 95 % CI = 1.27-1.78) increased risk of ADHD symptoms in the offspring of mothers experiencing antenatal and postnatal depression, respectively.

CONCLUSION

Our systematic review and meta-analysis identified an elevated risk of ADHD symptoms in the offspring of mothers who experienced both antenatal and postnatal depression. These findings underscore the importance of early screening and targeted intervention programs for at-risk children and adolescents.

Factors Associated with the Development of Depression and the Influence of Obesity on Depressive Disorders: A Narrative Review

Depression affects several aspects of life, including socioeconomic status, relationships, behavior, emotions, and overall health. The etiology of depression is complex and influenced by various factors, with obesity emerging as a significant contributor. This narrative review aims to investigate the factors associated with the development of depression, with a particular focus on the role of obesity. The literature search was conducted on PubMed, Embase, and PsycINFO from May to July 2024. The review highlights the impact of environmental and socioeconomic conditions; lifestyle choices, including physical activity and dietary habits; stress; traumatic experiences; neurotransmitter imbalances; medical and psychological conditions; hormone fluctuations; and epigenetic factors on depression. A key emphasis is placed on the inflammatory processes linked to obesity, which may drive the bidirectional relationship between obesity and depression. The findings suggest that obesity is associated with an increased risk of depression, potentially due to chronic inflammation, neurochemical dysregulation, and the emotional and social challenges related to weight stigma and obesity management. Understanding these interconnected factors is important for developing targeted interventions to address both obesity and depression, leading to improved quality of life for those affected.

The experience of Thai adolescents with depression: A qualitative study

AIM

People who have depression experience a maelstrom of emotion as they attempt to understand what is happening to them. While the experience has been quite extensively documented in adults and older individuals, there is a great deal less information available about adolescent depression experiences and reactions. The purpose of this study was to investigate the experiences of Thai-adolescents suffering from depression.

DESIGN

Interpretative phenomenological analysis.

METHOD

Fourteen adolescents were recruited from a secondary school in Chiangrai province, Thailand. Semi-structured interviews were carried out. Interviews were analysed using interpretative phenomenological analysis.

RESULTS

The following four themes were identified: (1) struggling to make sense of their situation, (2) feeling down and withdrawing, (3) contemplating self-harm and (4) therapy as a last choice. The results point to the continuing significance of promoting psychoeducation for Thai-adolescents with depression as well as parents, school nurses and health providers while eliminating stigma.

The ADHD Phenotype in Black and White Girls From Childhood to Adolescence: Results From the Community-Based Pittsburgh Girls Study

OBJECTIVE

The goal of the present study is to describe the ADHD phenotype from childhood to adolescence in Black and White girls in a community sample.

METHOD

Primary caregivers enrolled in the population-based, longitudinal Pittsburgh Girls Study reported on girls' ADHD symptoms and impairment from ages 7 to 17; diagnostic subtypes were estimated based on meeting symptom criteria.

RESULTS

The prevalence of any subtype of ADHD ranged from 6.4 to 9.2% and from 2.3 to 6.4% for Black and White girls respectively; the inattentive subtype was most endorsed. A relatively equal number of new diagnoses at each age was observed. Persistence of ADHD diagnoses was typically 1 to 2 years.

CONCLUSIONS

ADHD in the community is relatively common, with the inattentive subtype as the most common phenotype for Black and White girls. Research on developmentally sensitive periods for symptom exacerbation or new onset of ADHD in girls is needed.