Research reportAttention-deficit/hyperactivity disorder symptoms and suicide ideation and attempts: Findings from the Adult Psychiatric Morbidity Survey 2007
Introduction
Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by persisting inattention and/or hyperactivity-impulsivity that affects functioning and development (American Psychiatric Association, 2013). Although initially regarded as a childhood condition (Volkow and Swanson, 2013), research has shown that depending on the definitional criteria used, impairing ADHD symptoms persist into adulthood for between 15% and 76% of individuals with childhood ADHD (Biederman et al., 2010, Faraone et al., 2006) with studies indicating that the prevalence of ADHD in the adult population ranges from 2.5% to 4.4% (Fayyad et al., 2007, Kessler et al., 2006, Simon et al., 2009). While there is some evidence that ADHD symptoms may diminish in adults with increasing age (Das et al., 2014), recent research has shown that both syndromatic and symptomatic forms of ADHD exist even in elderly adults (i.e. those aged 60–94) (Michielsen et al., 2012).
Evidence that ADHD symptoms persist across the life course (Guldberg-Kjär et al., 2013) has led to a growing body of research examining the effects of ADHD among adults. This has highlighted that ADHD impacts negatively on adult well-being across a number of different domains. In particular, ADHD has been linked with a variety of detrimental health outcomes, including a greater risk for suicidal behavior (Impey and Heun, 2012, Nigg, 2013). Research on childhood ADHD has shown for example, that the disorder is associated with an increased risk for suicidal ideation, and attempted and completed suicide by young adulthood (Barbaresi et al., 2013, Barkley and Fischer, 2005, Hinshaw et al., 2012, Sourander et al., 2009 [hyperkinetic behavior]). In addition, a recent study from Sweden that used register data and a matched cohort design to examine suicidal behavior in 51 707 patients with an ADHD diagnosis, found increased odds for both attempted [Odds ratio (OR)=3.62] and completed suicide (OR=5.91) (Ljung et al., 2014).
To date, however, there has been comparatively little focus on the association between ADHD and suicidal behavior (Barkley, 2014), especially among the general adult population. The population-based research among adults that has been conducted has indicated that comorbidity with other psychiatric disorders may be particularly important for this association. A study from the United States using nationally representative data found that although there was a weak positive relationship between diagnosed ADHD and attempted suicide (OR=1.5) among adults aged 18–44, the relation was significantly stronger among those with one (OR=4.3) or two or more comorbid disorders (OR=12.4) (Agosti et al., 2011). Another study using data from Korean community-based adults aged 18–59 years found that a positive and statistically significant association between ADHD and suicidal behavior (ideas, plans, attempts) became non-significant when other psychiatric disorders were included in the analysis (Park et al., 2011). These results provide support for the conclusion of an earlier review of the association between ADHD and suicide which suggested that the relation was at best modest, and primarily due to ADHD exacerbating the effects of other comorbid conditions (James et al., 2004). In contrast, a recent study from Sweden found that there was a strong relation between ADHD and suicide attempts/deaths independent of psychiatric comorbidity (Ljung et al., 2014).
Given the limited research on the association between ADHD and suicidal behavior among adults, uncertainty concerning the role of comorbid mental conditions, and that a recent review of ADHD and suicidal behavior highlighted the need for more research among larger populations (Impey and Heun, 2012), the aim of this study was to examine the association between ADHD symptoms and suicidal behavior in a nationally representative sample of household-based adults in England. This may be a particularly apposite setting to investigate these associations. Recent research has highlighted that although the prescription of ADHD drugs to adults in the United Kingdom has increased (McCarthy et al., 2012), it is estimated that still less than one in ten adults with ADHD are receiving needed treatment (Bolea-Alamañac et al., 2014). At the same time, the male suicide rate in the UK has increased significantly in recent years (Office for National Statistics, 2015). In this situation, gaining a better understanding of the association between ADHD symptoms and suicide ideation and attempts among the general adult population will be essential for any future efforts to prevent this behavior, for example, by alerting health care professionals to the possible suicide risk in patients with ADHD (Furczyk and Thome, 2014).
In an attempt to extend earlier research and further elucidate possible relations, the current study examined the association between ADHD and suicide ideation and attempts by categorizing ADHD in two different ways to determine if the number/severity of symptoms might be important for this association. Using earlier research as a guide it was hypothesized that: (1) ADHD would be linked to both suicide ideation and attempts; (2) that the association might be stronger in respondents with more symptoms; (3) that comorbid psychiatric disorders would attenuate these associations.
Section snippets
Study sample
This study used data from 7403 people who participated in the Adult Psychiatric Morbidity Survey (APMS) 2007. Details of the survey have been published elsewhere (Jenkins et al., 2009, McManus et al., 2009). This survey was undertaken by the National Center for Social Research and Leicester University in October 2006 to December 2007. In order to obtain a representative sample of the English adult population (aged ≥16 years) residing in private households, multistage stratified probability
Results
There were 7403 respondents, with men comprising 48.6% and women 51.4% of the sample. The average age was 46.34 (standard deviation 18.60). When using the ASRS ≥14 cut-off score, 5.7% of the participants were categorized as belonging to the ADHD group (male 6.1% and female 5.4%). Details of the sample by the ADHD symptom cut-off score are presented in Table 1. For all characteristics besides sex, education (qualification) and ethnicity, there were statistically significant differences between
Discussion
This study examined the association between ADHD symptoms and suicide ideation and attempts in the English adult general household population. When an ASRS score of 14 was used as a cut-off point, 5.7% of the sample was classified as having possible ADHD with a similar prevalence among men (6.1%) and women (5.4%). Logistic regression analysis showed that there was a positive and statistically significant relation between ADHD symptoms and both lifetime and past 12-month suicide ideation and
Conclusion
The finding that adults with ADHD symptoms in the general population have an increased risk for suicide ideation and attempts has important research and clinical implications. In terms of the former, it underlines the need for more research on the association between adult ADHD and suicidal behavior in general community samples in order to better understand this relation and the factors associated with it. Regarding the latter, it highlights the importance of detecting and treating adult ADHD (
Role of funding source
AK’s work was supported by the Miguel Servet contract financed by the CP13/00150 project, integrated into the National R+D+I and funded by the ISCIII - General Branch Evaluation and Promotion of Health Research - and the European Regional Development Fund (ERDF). The sponsors played no role in the study design, in the analysis and interpretation of data; in the writing of the manuscript, or in the decision to submit it for publication.
Acknowledgements
We would like to thank the National Center for Social Research and Leicester University who were the survey’s principal investigators. We would also like to thank the UK Data Archive and the National Center for Social Research as the data collectors and for making these data publically available. They bear no responsibility for this analysis or interpretation of this publically available dataset.
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