Naturalistic Pharmacotherapy Compliance among Pediatric Patients with Attention Deficit/Hyperactivity Disorder: a Study Based on Three-Year Nationwide Data

Medication adherence and persistence in children and adolescents with attention deficit hyperactivity disorder (ADHD): a systematic review and qualitative update

Low medication-adherence and persistence may reduce the effectiveness of ADHD-medication. This preregistered systematic review (PROSPERO CRD42020218654) on medication-adherence and persistence in children and adolescents with ADHD focuses on clinically relevant questions and extends previous reviews by including additional studies. We included a total of n = 66 studies. There was a lack of consistency in the measurement of adherence/persistence between studies. Pooling the medication possession ratios (MPR) and using the most common adherence definition (MPR ≥ 80%) indicated that only 22.9% of participants had good adherence at 12-month follow-up. Treatment persistence on medication measured by treatment duration during a 12-month follow-up averaged 170 days (5.6 months). Our findings indicate that medication-adherence and persistence among youth with ADHD are generally poor and have not changed in recent years. Clinicians need to be aware that various factors may contribute to poor adherence/persistence and that long-acting stimulants and psychoeducational programs may help to improve adherence/persistence. However, the evidence to whether better adherence/persistence contributes to better long-term outcomes is limited and requires further research.

Drug survival and risk factors for ADHD medication discontinuation in adults: A Danish Nationwide Registry-based cohort study

INTRODUCTION

Attention deficit hyperactivity disorder (ADHD) medication has proven effective for treating ADHD in adults, nonetheless previous studies have shown high rates of medication discontinuation.

OBJECTIVE

To assess drug survival and identify risk factors associated with discontinuation of ADHD medication.

METHODS

A nationwide registry-based cohort study in Danish adults who redeemed a prescription for ADHD medication for the first time between 2010 and 2015. All patients were followed for 5 years from the first redeemed prescription. Discontinuation was defined as a gap of 12 months between redemptions. Logistic regression analysis with odds ratio (OR) and Kaplan Meier analysis were used to examine risk factors (sex, age, socioeconomic status, substance use disorders, and comorbidities) associated with discontinuation.

RESULTS

Twenty three thousand nine-hundred and sixteen patients with ADHD were identified. The 5-year overall drug survival was 29% in women vs. 23.5% in men. The risk of medication discontinuation was significantly higher in men compared to women, OR 1.26 (95% CI 1.19-1.34, p < 0.001). Adults aged 31-50 years had a significantly decreased risk of medication discontinuation compared to adults aged 18-30 years, OR 0.57 (95% CI 0.53-0.61, p < 0.001). Switching ADHD medication two times or three times or more significantly decreased the risk of discontinuation; OR 0.53 (95% CI 0.49-0.56, p < 0.001) and OR 0.26 (95% CI 0.23-0.30, p < 0.001), respectively. Substance use disorders and certain comorbidities were associated with medication discontinuation. Eating disorders, OR 0.71 (95% CI 0.64-0.78, p < 0.001), intellectual disabilities, OR 0.65 (95% CI 0.59-0.73, p < 0.001) and sleep disorders, OR 0.42 (95% CI 0.37-0.49, p < 0.001) were associated with continuation of ADHD medication.

CONCLUSIONS

The 5-year overall drug survival was longer in women compared to men. Women with ADHD; adults aged 31-50; and patients with comorbid eating disorder; intellectual disability; sleep disorder and medication switching were individually associated with continuation of ADHD medication. Various factors were associated with medication discontinuation. Discontinuation should be acknowledged as a common phenomenon in patients with ADHD and calls for increased attention from the treatment responsible prescriber or team. Moreover, our findings suggest that timely, frequent medication switching, or temporary regimens may indeed represent optimal management strategies for a significant proportion of the ADHD population.

Combined Medication with Stimulants and Non-stimulants for Attention-deficit/hyperactivity Disorder

Objective

To study the efficiency and indication of combined medication with a stimulant and non-stimulant for attention-deficiency/hyperactivity disorder (ADHD), herein, the authors examined children and adult patients with ADHD.

Methods

Subjects included patients diagnosed with ADHD who paid two or more visits to the outpatient clinic of the Kyung Hee University hospital from January 2009 to December 2019. The authors examined the age, sex, drugs, treatment adherence, and reason for combined medication. The subjects were classified into four groups treatment with a non-stimulant (atomoxetine) only (Group ATX), treatment with a stimulant (methylphenidate immediate-release, extended-release, or osmotic-release oral system) only (Group MPH), exposed to both but separately used (Group SEP), and exposed to both with combined use (Group COM). The patient was considered adherent to treatment (1) on visiting the hospital ten or more times or consecutively for six months, and (2) medication possession ratio ≥ 0.8.

Results

Of 929 patients, 229 (24.7%) were female. Group ATX comprised 146 (15.7%) patients, Group MPH comprised 627 (67.5%) patients, Group SEP comprised 106 (11.4%) patients, and Group COM comprised 50 (5.4%) patients. Longer-term adherence was seen with combined medication and in females than with monopharmacy and in males. The main indication for combination was dose-limiting untoward effects.

Conclusion

These results suggest that combined medication would facilitate treatment adherence for ADHD. Further research is essential for the replication of these results in a large sample and the investigation of the indications for administering combined medication in children and adults with ADHD.

Adherence to treatment in paediatric patients - results of the nationwide survey in Poland

Background

Due to high prevalence, non-adherence to prescribed treatment seriously undermines the effectiveness of evidence-based therapies in paediatric patients. In order to change this negative scenario, physicians need to be aware of adherence problem, as well as of possible solutions. Unfortunately, full potential of adherence-targeting interventions is still underused in Poland. Therefore, the aim of this study was to assess the knowledge, attitudes and behaviours toward non-adherence in Polish paediatricians.

Methods

An anonymous cross-sectional nationwide survey was conducted in the convenience sample of Polish doctors providing care to paediatric patients. The survey focused on the prevalence of non-adherence, its causes, and interventions employed. Primary studied parameter was perceived prevalence of non-adherence in paediatric patients. Reporting of this study adheres to STROBE guidelines.

Results

One thousand and thirty-three responses were eligible for analysis. Vast majority of respondents were female (85.9%), most of them worked in primary care (90.6%). The respondents represented all 16 Polish Voivodeships, with the biggest number coming from the Mazowieckie Voivodeship (n = 144, 13.9%). Survey participants believed that on average 28.9% of paediatric patients were non-adherent to medication. More than half of the respondents (n = 548, 53.0%) were convinced that their own patients were more adherent than average. Duration of the professional practice strongly correlated with a lower perceived prevalence of non-adherence. Professionals with more than 40 years of practice believed that the percentage of non-adherent patients was <=20% particularly often (OR = 3.82 (95% CI 2.11–6.93) versus those up to 10 years in practice). Out of all respondents, they were also most often convinced that their own patients were more adherent than the general population (P < 0.01). Consequently, they underestimated the need for training in this area.

Conclusions

Physicians taking care of Polish paediatric patients underestimated the prevalence of medication non-adherence and believed that this was a problem of other doctors. This optimistic bias was particularly pronounced in older doctors. These results identify important barriers toward improving patient adherence that are worth addressing in the pre- and post-graduate education of Polish physicians. They also put some light over the challenges that educational activities in this area may face.

Comparison of Persistence and Adherence Between Adults Diagnosed with Attention Deficit/Hyperactivity Disorder in Childhood and Adulthood

PURPOSE

Long-term treatment of attention deficit/hyperactivity disorder (ADHD) is important, but adherence and persistence in practice are still suboptimal. To better understand medication compliance for ADHD, we divided adults with ADHD into groups based on their history of childhood and adolescent ADHD, and compared their characteristics, medication adherence and persistence, and associated factors.

PATIENTS AND METHODS

This study included participants aged 18-23 years with claims related to ADHD (International Classifications of Diseases 10th edition, F90.0x) and anti-ADHD medication from July 1, 2017 to December 31, 2018, and with a history of any F90.0x claim(s) from January 1, 2007 to June 30, 2017 in the Korean National Health Insurance System Claims database. Participants were divided into those diagnosed with ADHD in childhood and adulthood. Persistence with or without a 30-day gap and adherence according to a medication possession ratio (MPR) >80% were calculated.

RESULTS

There were 10,604 patients included in the study. Adults with a childhood diagnosis of ADHD showed significant male predominance, more use of National Health Insurance, and were more often treated by psychiatrists and in hospitals than those with an adulthood diagnosis. Combination therapy was the most common initial treatment in those with an adulthood diagnosis, while monotherapy with Concerta was most common in those with a childhood diagnosis. Both groups had over 60% of participants with an MPR >80% and over 50% with persistence without a 30-day gap. Treatment in a private clinic and initial monotherapy with bupropion were found to be significantly associated with adherence in both groups.

CONCLUSION

The significant differences found between these groups add evidence to suggest that adult with ADHD diagnosed in adulthood may be a separate entity from those in childhood. A thorough evaluation at diagnosis and treatment in private clinics may improve medication compliance in this population.

Patterns of the Diagnosis Prevalence of Psychiatric Disorders in the Population Aged 0-18 Years Based on the Nationwide Insurance Sample Data

Objectives

This study aimed to examine the trend in diagnostic prevalence of psychiatric disorders in children and adolescents.

Methods

Individuals aged 0–18 years were included in the study based on the National Health Insurance Claims Data. To investigate the trends in diagnosis and diagnostic prevalence of psychiatric disorders reflecting the decrease in the birth rate, data were analyzed from 2010 as a reference year to 2015.

Results

The number of patients diagnosed with psychiatric disorder decreased annually, from 23,412 on 2010 to 18,821 on 2015. The most common disorder was hyperkinetic disorder in male and depressive episode in female. Although there was no significant change in overall diagnostic prevalence rate of psychiatric disorders, age groups <10 years and some disorders had significant changes in prevalence rate. This study classified the diagnostic prevalence by age into two unique patterns: group in which the diagnosis rate increases with age and group in which the diagnosis rate peaks at a certain age and then decreases.

Conclusion

Diagnostic prevalence of psychiatric disorders was different according to age and sex. These patterns should be reflected in the formulation of policies related to mental health and in medical practice for pediatric patients. It is urgent to identify how these patterns change in young adults.

A Review of Factors Influencing the Three Phases of Medication Adherence in People with Attention-Deficit/Hyperactivity Disorder

Objectives: Factors affecting adherence to medications in people with attention-deficit/hyperactivity disorder (ADHD) are not well understood in the context of their influence on the different phases of adherence, that is, initiation, implementation, and discontinuation. This review aimed to identify the factors affecting the three phases of medication adherence in people with ADHD. Methods: Six electronic databases, including Medline, PubMed, IPA, CINAHL, Embase, and PsycINFO, were systematically searched from inception through October 2018 with the limitations of English language and human studies. The search strategy was based on three concepts (adherence, ADHD, and factors) and their relevant terminologies. Results: Considerable variability was observed with regards to the criteria used to define adherence in identified studies (n = 48). Most studies focused on the implementation phase of adherence (n = 27), while only a handful focused on the initiation (n = 6) and discontinuation (n = 5) phase of adherence. The remaining studies (n = 10) examined multiple phases of adherence. Conflicting information received about medication, medication frequency, and fears of medication's effect on growth were the unique factors impacting initiation, implementation, and discontinuation, respectively. Moreover, factors within each phase of adherence also differed with different populations such as parents, children, adolescents, and adults. Fear of addiction, medication effectiveness, psychiatric comorbidity, and medication side effects were the most common factors identified in all three phases of adherence. Conclusions: This review found some unique factors in each phase of adherence while some overlap was also noted. Future interventions to improve adherence should be phase- and group specific rather than consider adherence as a single variable.

The association between methylphenidate treatment and the risk for fracture among young ADHD patients: A nationwide population-based study in Taiwan

Attention-deficit hyperactivity disorder (ADHD) is associated with higher risk for fracture. Whether the medical treatment for ADHD would mitigate the risk remains unclear. In this study, we sought to investigate the effect of methylphenidate treatment on risk for fracture, as well the moderational role of treatment duration on the risk of fracture, in a large national sample. Cases less than 18 years old were identified from Taiwan's National Health Insurance Research Database with a new primary diagnosis of ADHD (ICD-9:314) between 1996 and 2013. A total of 6201 cases with ADHD were included as the study cohort. The cases were divided into 3 groups according to the duration of methylphenidate treatment (0, 1-180, and more than 180 days). All groups were followed until the end of 2013 for first diagnoses of fracture (ICD-9 codes 800 to 829). Cox proportional hazards models were applied. Compared to the group without methylphenidate treatment, the risk for fracture was lower among the group treated for more than 180 days. The adjusted hazard ratio was 0.77 (95% Confidence interval: 0.63-0.94). The groups treated for 180 days or fewer had no significant difference in the risk for fracture. In conclusion, methylphenidate treatment was associated with lower risk for fracture among ADHD patients. The association was evident only in the cohort treated for more than 180 days.

Beliefs regarding medication and side effects influence treatment adherence in adolescents with attention deficit hyperactivity disorder

Adherence to attention deficit hyperactivity disorder (ADHD) treatment is important because, when untreated, it may have serious consequences with lifelong effects. In the case of adolescents on long-term medicine prescription, more knowledge is needed regarding adherence and factors influencing adherence, which was the purpose of this study. Adolescents (n = 101) on ADHD medication ≥6 months were administrated questionnaires at a monitoring appointment: Medication Adherence Report Scale (MARS), beliefs about medicines (BMQ) and the Brief Illness Perception Questionnaire (B-IPQ). Adherence was high, the mean value was 88% of the maximum MARS score, and correlated positively with the "BMQ-necessity-concerns differential" but negatively with "BMQ-concerns" and "BMQ-side effects". Adolescents with more belief in the necessity of the medication, less concerns and less experience of side effects tended to be more adherent to medication prescription ("intentional non-adherence"), while "unintentional non-adherence" (forgetfulness) was associated with how much they perceived that their ADHD affected their lives. In a multiple regression model, the variance of MARS total (R ² = 0.21) and "intentional non-adherence" (R ² = 0.24) was explained by the "BMQ-necessity-concern differential" and "BMQ-experienced side effects". The variance of "unintentional non-adherence" (R ² = 0.12) was explained by the "BMQ-necessity-concern differential" and "B-IPQ-consequences of ADHD". In conclusion, adolescents on long-term medication reported good adherence, mainly influenced by more beliefs in the necessity versus concerns of the medications, less experienced side effects and more perceived consequences of ADHD. BMQ could be useful to identify risks of low adherence, which should be counteracted by partially gender-specific interventions.