Prevalence of adult attention deficit hyperactivity disorder and comorbid axis-i disorders among first time admitted cases of A general psychiatry outpatient clinic and A family counselling center

OBJECTIVE: The primary objective of this study was to identify the prevalence of adult attention deficit hyperactivity disorder (ADHD) among first time admitted consecutive cases of a university hospital general psychiatry outpatient clinic and a family counselling center. Second aim of the study was to define the causes of admissions to this centers and prevalence of comorbid axis-I disorders in adult ADHD cases. METHOD: This study was a cross-sectional epidemiological study conducted in general psychiatry outpatient clinic of Ege University Faculty of Medicine and Psikoaktif Family Counselling Center linked to Ministry of Family and Social Policies. After having provided written informed consent of cases which does not meet any exclusion criteria before clinical assessment were given to Adult ADHD Self-Report Scale (ASRS), Turgay's Adult ADD/ADHD DSM-IV Based Diagnostic Screening and Rating Scale, Wender Utah Rating Scale (WURS) and the case report form used in this study. Positively screened cases according to ASRS (at least 4 out of 6 responses exceeding threshold in Part A) or Turgay's Adult ADD/ADHD DSM-IV Based Diagnostic Screening and Rating Scale (at least 5 out of 9 responses exceeding threshold in Part 1 or 2) were clinicially assessed in general psychiatry outpatient clinic. Positively screened cases of family counselling center according to at least one of these screening tests were invited to Ege University Faculty of Medicine via telephone for clinical assessment. In this study two different screening tests were used to increase sensitivity. Diagnostic Interview for ADHD in Adults (DIVA 2.0) were applied to positively screened cases for ADHD diagnosis. DSM-5 criteria were taken into consideration in ADHD diagnostic interviews. Whenever possible the DIVA 2.0 was completed with the patients first degree relatives to enable retrospective and collateral information; information received via telephone was also accepted. Patients who were diagnosed with adult ADHD via DIVA 2.0 were evaluated by Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I). WURS was used to evaluate childhood ADHD symptoms and cut-off score was 36 or higher in this study. These interviews were completed approximately in 2 hours in a single session. RESULTS: The prevalence of adult ADHD according to DSM-5 criteria in general psychiatry outpatient clinic including 210 individuals was 14,3% (n=30). The prevalence of adult ADHD in family counselling center including 133 individuals was 9,8% (n=13). According to SCID-I the most common type of comorbid psychiatric disorders among ADHD diagnosed patients of general psychiatry outpatient clinic were depressive disorder (40%), specific phobia (26,7%), alcohol abuse (16,7%), dysthymic disorder (16,7%) and obsessive-compulsive disorder (13,4%), respectively. The most common type of comorbid psychiatric disorders among ADHD diagnosed patients of family counselling center were depressive disorder (46,1%) and alcohol abuse (23,1%). 80% of ADHD patients in general psychiatry outpatient clinic were diagnosed with at least one additonal psychiatric disorder and 46,7% were diagnosed with more than one additonal psychiatric disorder; it was 84,6% and 30,8% for family counselling center, respectively. Patients with ADHD in general psychiatry outpatient clinic had higher ASRS (z=-2,345; p=0,019) and Turgay's Adult ADD/ADHD DSM-IV Based Diagnostic Screening and Rating Scale Part-3 (Part of problems and features of ADHD) (z=-2,461; p=0,014) scores than patients with ADHD in family counselling center; WURS scores were also higher but it was not statistically significant (z=-1,045; p=0,296). Patients with ADHD in general psychiatry outpatient clinic reported more disciplinary penalty at school (χ²=9,210; p=0,011), frequent job change (χ²=11,989; p=0,002), problem with police unit (χ²=8,68; p=0,009), occupational/home accident (χ²=5,501; p=0,028) than patients without ADHD. Patients with ADHD in family counselling center reported more disciplinary penalty at school (χ²=18,423; p=0,001), problem with police unit (χ²=11,997; p=0,005) and judicial problem (χ²=5,466; p=0,035) than patients without ADHD. Patients with ADHD in general psychiatry outpatient clinic (χ²=1,776; p=0,180) and family counselling center (χ²=3,263; p=0,090) reported more suicide attempts than patients without ADHD; but it was not statistically significant. 16,7% of patients with adult ADHD in general psychiatry outpatient clinic and 30,8% of patients with adult ADHD in family counselling center have been diagnosed with ADHD in childhood. Only 30% of patients with ADHD in general psychiatry outpatient clinic and only 15,4% of patients with ADHD in family counselling center were admitted suspecting they had an ADHD. When we look at their causes of admission, it is seen that patients with ADHD in family counselling center reported more marriage/relationship problems (84,6% vs 49,5%) (χ²=5,680; p=0,037), personal problems (53,8% vs 14,7%) (χ²=11,166; p=0,003) and educational problems (46,2% vs 9,5%) (χ²=12,864; p=0,003) than patients without ADHD; also reported more occupational problems (30,8% vs 10,5%) (χ²=4,153; p=0,064) but it was not statistically significant. In general psychiatry outpatient clinic there were statistically no significant difference between ADHD and non-ADHD patients in terms of causes of admission. 54% of positively screened family counselling center cases of ADHD did not accept the invitation to hospital which was done with the aim of further clinical assessment. CONCLUSION: In this study we found the prevalence of adult ADHD in general psychiatry outpatient clinic and family counselling center much higher than estimates for general adult population. Almost all adult ADHD patients of both centers had at least one additional psychiatric disorder. It is seen that it was more severe form of ADHD in general psychiatry outpatient clinic; even though it was not statistically significant, the prevalence of having more than one additional psychiatric disorder in ADHD patients of general psychiatry outpatient clinic was higher than family counselling center ADHD patients. Adult ADHD patients which have marriage/relationship, personal, educational and occupational problems preferred admission to a family counselling center expecting a treatment method other than pharmacotherapy. During the study we met with some difficulties in referral of probably ADHD diagnosed cases of family counselling center to the hospital for a clinical assessment. It seems that adult ADHD diagnosis is missing in general psychiatry outpatient clinics because of prevalent comorbid psychiatric disorders and missing in family counselling centers because of other prominent everyday life problems. It is hoped that data from this study contribute to a better understanding of the prevalence and clinical presentations of adult ADHD patients and their causes of admissions to general psychiatry outpatient clinic and family counselling centers. To our knowledge, this is the first study to evaluate the prevalence of adult ADHD, their clinical presentation and causes of admissions in a group expecting treatment method other than pharmacotherapy. However, further studies in other mental health centers with a larger sample sizes are needed to improve the knowledge and experience in this field. Keywords: Adult attention deficit hyperactivity disorder; comorbidity; family counselling center; prevalence; psychiatry outpatient clinic