A Novel Text Message Intervention to Improve Adherence to Stimulants in Adults With Attention Deficit/Hyperactivity Disorder.

BACKGROUND: Attention deficit/hyperactivity disorder (ADHD) is a prevalent neurobiological disorder associated with a wide range of adverse outcomes. Although large data sets document that stimulants decrease the risks for many ADHD-associated adverse outcomes, compliance with stimulants remains very poor. The main aim of this study was to assess the effectiveness of a novel text messaging-based intervention aimed at improving the poor rate of adherence to stimulant medications in adults with ADHD. METHODS: Subjects were adults with ages 18 to 55, prescribed a stimulant medication for ADHD treatment. For comparators, we identified at a 5-to-1 ratio (age and sex matched) adult patients from the Partners HealthCare electronic medical record who had been prescribed stimulant medications over a 1-year period. We determined whether patients had timely prescription refills, defined as refilled within 37 days, using prescriptions documented in their electronic medical record. RESULTS: Our results showed that 68% of the SMS intervention group refilled their prescriptions in a timely manner. In contrast, only 34% of patients receiving treatment as usual refilled their prescriptions in a timely fashion (odds ratio, 4.04; 95% confidence interval, 2.49-6.56; P < 0.001). CONCLUSIONS: These data indicate that an innovative ADHD-centric text messaging intervention significantly improved patient engagement to treatment with stimulants in adults with ADHD. Findings provide strong support for the use of a readily accessible, inexpensive, and widely available technology to improve the poor rate of adherence to stimulant treatment in adults with ADHD. To the best of our knowledge, this study is the first digital health intervention aimed at improving adherence to stimulant medication for adults with ADHD.

Are Adult ADHD Patients Good Informants of Their Symptoms? A Qualitative Literature Review of Concordance Between Clinician and Self-Report ADHD Symptoms.

To conduct a comprehensive review on the agreement between clinician-rated and self-reported attention-deficit/hyperactivity disorder (ADHD) symptoms in adults, the following terms were searched in PubMed: "ADHD self-concordance," "Self-report AND ADHD AND Valid," "(self-report) AND ADHD AND clinician," and "(self-report) AND ADHD AND versus AND investigator." Nine articles met our inclusion and exclusion criteria (English language, operationalized measures of clinician-rated and self-reported ADHD, and neither a review nor opinion article). Among the clinical studies, correlation coefficients were on average 0.69 for the total ADHD symptoms score. The epidemiological studies had an average kappa statistic of 0.58 for ADHD diagnoses. The studies of adult relatives of youth with ADHD had an average correlation coefficient of 0.74 for the ADHD total symptoms score. Our review supports the informativeness of self-reported assessments of ADHD symptoms, which has important implications for management and monitoring of ADHD.

Informativeness of Self-Reports of ADHD Symptoms in Monitoring Response to Stimulant Treatment in Clinically Referred Adults With ADHD.

Objective: To investigate the informativeness of self-reports of ADHD symptoms in adults with ADHD in the clinical setting. Method: Subjects were clinically referred adults aged 19 years to 67 years of age of both sexes (N = 54). All subjects were on stable doses of stimulant and were considered responders to treatment. ADHD symptoms were assessed using the ADHD Investigator Symptom Rating Scale (AISRS) and the ADHD Self-Report Scale (ASRS). Spearman's rank correlations were used to assess the correlations between clinician-assessed ADHD and patients' self-reports. Results: Spearman's rank correlation analysis found evidence of a strong, positive association between total scores on the AISRS and the ASRS (rs = .65, df = 52, p< .001). Conclusion: Results have important implications for the management and monitoring of treatment response in the clinical setting through patients' self-report.

Further evidence of low adherence to stimulant treatment in adult ADHD: an electronic medical record study examining timely renewal of a stimulant prescription.

RATIONALE: ADHD is a prevalent and morbid neurobiological disorder affecting up to 5% of adults. While stimulants have been documented to be safe and effective in adults with ADHD, uncertainties remain about adherence to these treatments. OBJECTIVES: The main aim of this article was to evaluate contemporaneous rates and correlates of adherence to stimulants in adults with ADHD using data from electronic medical records from a large healthcare organization focusing on timely renewal of an initial prescription. METHODS: Subjects were patients 18 to 44 years of age who had been prescribed a stimulant between January 1, 2015, and December 31, 2016. Prescription and sociodemographic data were extracted from the Partners HealthCare Research Patient Data Registry (RPDR). Our outcome metric was renewal of the index stimulant prescription defined as the first prescription recorded in the electronic record for the period under investigation. RESULTS: We identified 2689 patients with an index prescription for a stimulant medication. Results showed that only 42% of patients renewed their prescriptions in a timely enough fashion to be considered consistently medicated. CONCLUSIONS: Results indicate that adults with ADHD have a low rate of renewal of their initial stimulant prescription indicating poor patient engagement in their treatment for ADHD.

A novel digital health intervention to improve patient engagement to stimulants in adult ADHD in the primary care setting: Preliminary findings from an open label study.

AIMS: We piloted the effectiveness and acceptability of a novel text messaging-based (SMS) digital health intervention aimed at addressing the previously documented poor rate of patient engagement in stimulant treatment in the primary care setting. METHODS: 117 adults ages 18-55 from primary care and psychiatric practices who were prescribed a stimulant medication for ADHD treatment received the SMS intervention. Comparators were age-, race-, and sex-matched patients from the same health care organization's electronic medical record who had been prescribed stimulant medications over a similar time period. Using documented prescription records, we determined whether patients had timely prescription refills. RESULTS: Ninety-six percent (N = 112) of participants completed our a priori metric of patient engagement consisting of 37 days of the SMS program. Eighty-one percent of participants refilled their index prescriptions in a timely manner compared to only 36% of patients receiving treatment as usual (OR=7.54, 95% CI: 4.46, 12.77; p<0.001). We found no significant interaction between prescribing source (non-psychiatry vs. psychiatry) and intervention group (SMS vs. treatment as usual). CONCLUSIONS: These data suggest that an ADHD-centric, digital health intervention using text messaging significantly improves patient engagement in stimulant treatment in adults with ADHD.

Toward operationalizing deficient emotional self-regulation in newly referred adults with ADHD: A receiver operator characteristic curve analysis.

BACKGROUND: A growing body of research suggests that deficient emotional self-regulation (DESR) is common and morbid among attention-deficit/hyperactivity disorder (ADHD) patients. The main aim of the present study was to assess whether high and low levels of DESR in adult ADHD patients can be operationalized and whether they are clinically useful. METHODS: A total of 441 newly referred 18- to 55-year-old adults of both sexes with Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition (DSM-5) ADHD completed self-reported rating scales. We operationalized DESR using items from the Barkley Current Behavior Scale. We used receiver operator characteristic (ROC) curves to identify the optimal cut-off on the Barkley Emotional Dysregulation (ED) Scale to categorize patients as having high- versus low-level DESR and compared demographic and clinical characteristics between the groups. RESULTS: We averaged the optimal Barkley ED Scale cut-points from the ROC curve analyses across all subscales and categorized ADHD patients as having high- (N = 191) or low-level (N = 250) DESR (total Barkley ED Scale score ≥8 or <8, respectively). Those with high-level DESR had significantly more severe symptoms of ADHD, executive dysfunction, autistic traits, levels of psychopathology, and worse quality of life compared with those with low-level DESR. There were no major differences in outcomes among medicated and unmedicated patients. CONCLUSIONS: High levels of DESR are common in adults with ADHD and when present represent a burdensome source of added morbidity and disability worthy of further clinical and scientific attention.

An innovative SMS intervention to improve adherence to stimulants in children with ADHD: Preliminary findings.

BACKGROUND: Although large datasets document that stimulants decrease the risk for many adverse ADHD-associated outcomes, compliance with stimulants remains poor. AIMS: This study examined the effectiveness of a novel ADHD-centric text messaging-based intervention aimed to improve adherence to stimulant medications in children with ADHD. METHODS: Subjects were 87 children aged 6-12, who were prescribed a stimulant medication for ADHD treatment. Prescribers gave permission to contact their patients for participation in the study. Subjects were primarily from the primary care setting with a subsample of psychiatrically referred subjects for comparison. Age- and sex-matched comparators were identified (3:1) from the same pool of prescriber-approved subjects that did not participate. Timely prescription refills (within 37 days) were determined from prescription dates documented in patients' electronic medical record. RESULTS: Eighty-five percent of SMS intervention patients refilled their prescriptions in a timely manner compared with 62% of patients receiving treatment as usual (OR = 3.46, 95% CI: 1.82, 6.58; p < 0.001). The number needed to treat statistic was computed as five, meaning for every five patients who receive the SMS intervention, we can keep one adherent to their stimulant treatment. CONCLUSIONS: These preliminary findings support the potential utility of a readily accessible technology to improve the poor rate of adherence to stimulant treatment in children with ADHD. To the best of our knowledge, this study is the first digital health intervention aimed at improving adherence to stimulant medication for children with ADHD. These results support the need for further examination of this technology through more definitive randomized clinical trials.

Quantifying the Protective Effects of Stimulants on Functional Outcomes in Attention-Deficit/Hyperactivity Disorder: A Focus on Number Needed to Treat Statistic and Sex Effects.

PURPOSE: The aim of the study was to help quantify the protective effects of stimulant treatment on important functional outcomes in attention-deficit/hyperactivity disorder (ADHD) using the number needed to treat (NNT) statistic and examine whether these effects are moderated by sex. METHODS: Subjects were derived from three independent samples, two similarly designed case-control, 10-year prospective follow-up studies of boys and girls with and without ADHD grown up and a cross-sectional randomized clinical trial of lisdexamfetamine on driving performance and behavior. For all studies, subjects were evaluated with structured diagnostic interviews. To measure psychopharmacologic treatment in the follow-up studies, we collected information about each subject's stimulant medication use, age at onset, and age at termination of treatment. Subjects in the driving study underwent two driving simulation assessments (premedication and after 6 weeks of treatment on lisdexamfetamine or placebo). For each outcome, we ran a logistic regression model that included an interaction between sex and treatment status. Lifetime rates were used to calculate the NNT statistic. We also calculated adjusted NNT statistics that accounted for sex, age, socioeconomic status, and family intactness. RESULTS: The NNTs were very low, ranging from 3 to 10. No interaction effects with sex were detected (all p > .05). The adjusted NNTs mostly remained the same with the exception of any substance use disorder, which increased after controlling for age. CONCLUSIONS: Stimulants have strong protective effects on functional outcomes in youth with ADHD that are not moderated by sex. These results support the critical importance of early identification and treatment of children with ADHD of both sexes.

Clinical correlates of mind wandering in adults with ADHD.

The objective of this study was to investigate the prevalence and clinical correlates of ADHD patients with mind wandering. 255 consecutively referred 18- to 55-year-old adults of both sexes with ADHD were assessed. Subjects completed a demographic interview, the Mind Wandering Questionnaire (MWQ), the ADHD Rating Scale (ADHD RS), the Behavior Rating Inventory of Executive Function - Adult Version (BRIEF-A), the Social Responsiveness Scale - Second Edition (SRS-2) Adult Self-Report Form, the Adult Self-Report (ASR), the Barkley Emotional Dysregulation Scale, and the Quality of Life Enjoyment & Satisfaction Questionnaire (Q-LES-Q). We used receiver operator characteristic (ROC) curves to identify the optimal cut-off on the MWQ to categorize patients as having high-versus low-level mind wandering and compared demographic and clinical characteristics between the two groups. Participants were categorized by ROC analysis as having high- (N = 127) and low-level (N = 128) mind wandering based on an MWQ total score ≥ or < than 24, respectively. Compared with low-level mind wandering participants, those with high-level mind wandering had significantly more Inattentive and Hyperactive symptoms (all p < 0001), worse executive functioning as measured by the BRIEF-A, more impaired mean (all p ≤ 0.001) and dichotomized scores (t-score ≥65) (all p < 0.005) on subscales and composite ASR scales, more impaired scores on the Barkley Emotional Dysregulation Scale (p < 0.001), and more impaired quality of life scores. High-level mind wandering is prevalent in adults with ADHD and is associated with more severe ADHD symptoms, more executive function deficits, more emotional dysregulation, higher levels of associated psychopathology, and more impaired quality of life.

Evidence of Low Adherence to Stimulant Medication Among Children and Youths With ADHD: An Electronic Health Records Study.

OBJECTIVE: The objective of this study was to evaluate rates and correlates of stimulant medication adherence in a sample of pediatric patients using data derived from electronic medical records (EMRs) from a large health care organization in a large metropolitan area. The study relied on a novel definition of medication adherence as a timely renewal of an index prescription determined using the electronically recorded issuance of a stimulant prescription in the EMR ("refill"). METHODS: Prescription and sociodemographic data were extracted from the Partners HealthCare Research Patient Data Registry to calculate adherence to stimulant medication treatment. RESULTS: In the EMR, 2,206 patients with prescriptions for central nervous system stimulant medication were identified. Results showed that 46% of the index prescriptions were refilled within the timeframe necessary for the patient to be considered consistently medicated. A multivariable logistic regression model predicting medication adherence from patient demographic and treatment characteristics yielded an area-under-the-curve statistic of 0.57, indicating that these characteristics predicted adherence only modestly better than chance. CONCLUSIONS: EMR data from a large health care organization showed that 46% of pediatric patients were adherent to treatment with stimulants. Rates of medication adherence were worse among patients receiving care from a primary care provider than among those receiving care from a psychiatrist, in older patients, and in female patients and did not appear to be influenced by racial-ethnic group, economic class, stimulant type, or medication formulation (short or long acting). These findings, which show low rates of medication adherence among children and adolescents with ADHD, suggest the need for efforts to improve these rates.

Further Evidence of Morbidity and Dysfunction Associated With Subsyndromal ADHD in Clinically Referred Children.

BACKGROUND: While the diagnostic criteria for attention-deficit/hyperactivity disorder (ADHD) have evolved over the years, some children with impairing ADHD symptoms fail to meet the full diagnostic threshold for the disorder. The main aim of this study was to evaluate the morbidity and dysfunction of subsyndromal ADHD in the clinical setting. METHODS: Subthreshold and full ADHD subjects were derived from consecutive referrals (n = 2,947) to a pediatric psychopharmacology program at a major academic center. Subjects were diagnosed with subthreshold ADHD if they met at least 1 of the following criteria: (1) their age at onset for ADHD was ≥ 7 years; (2) they had ≥ 5 but < 8 ADHD symptoms using the DSM-III-R or ≥ 4 but < 6 ADHD inattentive or hyperactive/impulsive symptoms using the DSM-IV. Healthy controls were derived from 2 identically designed longitudinal case-control studies of youth with and without ADHD. Psychiatric assessments relied on clinical structured interviews and measures of psychopathology, social functioning, cognitive ability, and academic achievement. RESULTS: Of the 1,931 children diagnosed with ADHD, 140 (7%) were diagnosed with subthreshold ADHD. 48% of subthreshold ADHD subjects had an age at onset ≥ 7 years, and 73% had insufficient symptoms. Reanalysis of findings using DSM-5 criteria showed that only 21% of our subthreshold ADHD subjects would have met DSM-5 criteria based on age at onset of < 12 years, while 79% would have maintained their subthreshold diagnoses. Subjects with subthreshold ADHD differed from controls in the mean number of comorbid disorders; rates of mood, anxiety, and elimination disorders (all P < .001) and substance use disorders (P < .05); scores on all Child Behavior Checklist clinical and social functioning scales; scores on 7 of the 10 Social Adjustment Inventory for Children and Adolescents scales; rates of requiring extra help in school and being placed in a special class; and scores on 4 of the 5 Wechsler Intelligence Scale for Children-Revised Version subscales (excluding Digit Span) as well as in Freedom from Distractibility Index score (P < .001). Subthreshold and full ADHD subjects had similarly elevated Global Assessment of Functioning scores versus controls (P < .001), but subjects with subthreshold ADHD had fewer perinatal complications and better family functioning scores and were more likely to be female and older and to come from families of higher socioeconomic status than subjects with full ADHD. CONCLUSIONS: Clinically referred children failing to meet full-threshold diagnosis for ADHD due to either insufficient symptoms or later age at onset have patterns of clinical features highly similar to those with the full syndrome. These results extend to previously reported findings in nonreferred samples documenting the high morbidity and disability associated with subthreshold ADHD.

Does the course of manic symptoms in pediatric bipolar disorder impact the course of conduct disorder? Findings from four prospective datasets.

BACKGROUND: To assess whether the course of pediatric bipolar-I (BP-I) disorder impacts the course of conduct disorder (CD)/antisocial personality disorder (ASPD). We hypothesized that remission of manic symptoms in BP-I youth will be associated with remission of CD/ASPD. METHODS: We used data from four longitudinal datasets of carefully characterized and comprehensively assessed youth with structured diagnostic interview based diagnoses of BP-I disorder and CD/ASPD assessed at baseline in childhood and at follow-up onto adolescent years. The baseline sample consisted of 240 subjects with full BP-I disorder. The average follow-up time was 6.6 ±â€¯2.4 years. RESULTS: Subjects with remitting BP-I disorder in adolescent years had a significantly lower one-year prevalence of CD or ASPD compared to those with persistent BP-I disorder (χ2 = 10.35, p = 0.001). LIMITATIONS: Our inferences were derived from the examination of naturalistic longitudinal follow-up data and not results of a clinical trial. CONCLUSIONS: Results indicate that remission of manic symptoms at the adolescent follow up in youth with BP-I disorder were associated with a significant decrease in rates of CD/ASPD. These results suggest that targeting manic symptoms in youth with BP-I disorder could mitigate the course of CD/ASPD in youth. Considering the high morbidity and disability associated CD/ASPD in youth and the limited treatment options available to address it, if replicated, these findings would have very important clinical and public health significance.