Associations of asthma and psychiatric comorbidities on suicide mortality among community adolescents: A 20-year cohort study.

BACKGROUND: The role of psychiatric comorbidity as a confounder between asthma and subsequent suicide mortality in adolescents remained unclarified. METHODS: This study used a 20-year community-based cohort in Taiwan. Adolescents aged 11 to 16 from 123 schools were classified into three subgroups: current asthma (symptoms present in the past year), previous asthma (history of asthma but no symptoms in the past year), and no asthma. The mortality and medical care utilizations until the end of follow-up in 2015 were obtained. Cox proportional hazard and competing risk models were performed. Different adjustment models that included covariates of demographic status, allergy, cigarette smoking, psychiatric diagnoses, alcohol or substance misuse, and attention deficit and hyperactivity disorders were compared. RESULTS: During the follow-up, 285 out of 153,526 participants died from suicide. The crude hazard ratio for suicide was 1.95 (95 % CI=1.46∼2.60) in the current asthma subgroup and 2.01 (1.36∼2.97) in the previous asthma subgroup. The adjusted hazard ratios (aHR) attenuated to 1.67 (1.25∼2.24) and 1.72 (1.16∼2.54) respectively after further adjustment for all mental disorders, ADHD, substance, and alcohol use disorders. CONCLUSIONS: Our adjustment analyses stratified by different models highlight evidence of asthma as an independent risk factor that predicts suicide among adolescents. Depression and mental disorders were potential confounders and identifications of asthma and psychiatric disorders might help decrease suicide risk.

ADHD Pharmacotherapy and Mortality in Individuals With ADHD.

Importance: Attention-deficit/hyperactivity disorder (ADHD) is associated with increased risks of adverse health outcomes including premature death, but it is unclear whether ADHD pharmacotherapy influences the mortality risk. Objective: To investigate whether initiation of ADHD pharmacotherapy was associated with reduced mortality risk in individuals with ADHD. Design, Setting, and Participants: In an observational nationwide cohort study in Sweden applying the target trial emulation framework, we identified individuals aged 6 through 64 years with an incident diagnosis of ADHD from 2007 through 2018 and no ADHD medication dispensation prior to diagnosis. Follow-up started from ADHD diagnosis until death, emigration, 2 years after ADHD diagnosis, or December 31, 2020, whichever came first. Exposures: ADHD medication initiation was defined as dispensing of medication within 3 months of diagnosis. Main Outcomes and Measures: We assessed all-cause mortality within 2 years of ADHD diagnosis, as well as natural-cause (eg, physical conditions) and unnatural-cause mortality (eg, unintentional injuries, suicide, and accidental poisonings). Results: Of 148 578 individuals with ADHD (61 356 females [41.3%]), 84 204 (56.7%) initiated ADHD medication. The median age at diagnosis was 17.4 years (IQR, 11.6-29.1 years). The 2-year mortality risk was lower in the initiation treatment strategy group (39.1 per 10 000 individuals) than in the noninitiation treatment strategy group (48.1 per 10 000 individuals), with a risk difference of -8.9 per 10 000 individuals (95% CI, -17.3 to -0.6). ADHD medication initiation was associated with significantly lower rate of all-cause mortality (hazard ratio [HR], 0.79; 95% CI, 0.70 to 0.88) and unnatural-cause mortality (2-year mortality risk, 25.9 per 10 000 individuals vs 33.3 per 10 000 individuals; risk difference, -7.4 per 10 000 individuals; 95% CI, -14.2 to -0.5; HR, 0.75; 95% CI, 0.66 to 0.86), but not natural-cause mortality (2-year mortality risk, 13.1 per 10 000 individuals vs 14.7 per 10 000 individuals; risk difference, -1.6 per 10 000 individuals; 95% CI, -6.4 to 3.2; HR, 0.86; 95% CI, 0.71 to 1.05). Conclusions and Relevance: Among individuals diagnosed with ADHD, medication initiation was associated with significantly lower all-cause mortality, particularly for death due to unnatural causes.

Association of Psychiatric Comorbidity With the Risk of Premature Death Among Children and Adults With Attention-Deficit/Hyperactivity Disorder.

Importance: A previous register-based study reported elevated all-cause mortality in attention-deficit/hyperactivity disorder (ADHD), but cause-specific risks and the potential associations of psychiatric comorbidities remain unknown. Objectives: To investigate the all-cause and cause-specific mortality risks in ADHD and to explore the potential role of psychiatric comorbidities. Design, Setting, and Participants: This prospective cohort study used Swedish national registers to identify 2 675 615 individuals born in Sweden from January 1, 1983, through December 31, 2009, as the study population, among whom 86 670 individuals (3.2%) received a diagnosis of ADHD during follow-up. Follow-up was completed December 31, 2013, and data were analyzed from October 2018 through March 2019. Exposures: Attention-deficit/hyperactivity disorder identified by first clinical diagnosis or first prescription of ADHD medications as recorded in Swedish registers. Clinical diagnosis of psychiatric comorbidity was available in the National Patient Register. Main Outcomes and Measures: All-cause and cause-specific mortalities and hazard ratios (HRs) using Cox proportional hazards regression models. Results: In the overall cohort of 2 675 615 individuals, 1 374 790 (51.4%) were male (57 919 with an ADHD diagnosis) and 1 300 825 (48.6%) were female (28 751 with an ADHD diagnosis). Mean (SD) age at study entry was 6.4 (5.6) years. During follow-up, 424 individuals with ADHD and 6231 without ADHD died, resulting in mortality rates of 11.57 and 2.16 per 10 000 person-years, respectively. The association was stronger in adulthood (HR, 4.64; 95% CI, 4.11-5.25) compared with childhood (HR, 1.41; 95% CI, 0.97-2.04) and increased substantially with the number of psychiatric comorbidities with ADHD (HR for individuals with only ADHD, 1.41 [95% CI, 1.01-1.97]; HR for those with ≥4 comorbidities, 25.22 [95% CI, 19.60-32.46]). In adulthood, when adjusting for early-onset psychiatric comorbidity, the association between ADHD and risk of death due to natural causes was attenuated substantially and was no longer statistically significant (HR, 1.32; 95% CI, 0.94-1.85). When adjusting for later-onset psychiatric disorders, the association was attenuated to statistical nonsignificance for death due to suicide (HR, 1.13; 95% CI, 0.88-1.45) but remained statistically significant for death caused by unintentional injury (HR, 2.14; 95% CI, 1.71-2.68) or other external causes (HR, 1.75; 95% CI, 1.23-2.48). Conclusions and Relevance: Psychiatric comorbidity appears to play an important role in all-cause and cause-specific mortality risks in ADHD. In adulthood, early-onset psychiatric comorbidity contributed primarily to the association with death due to natural causes, whereas later-onset psychiatric comorbidity mainly influenced death due to unnatural causes, including suicide and unintentional injury. These findings suggest that health care professionals should closely monitor specific psychiatric comorbidities in individuals with ADHD to identify high-risk groups for prevention efforts.

Attention-Deficit/Hyperactivity Disorder and Mortality Risk in Taiwan.

Importance: Few studies have investigated levels of mortality in patients with attention-deficit/hyperactivity disorder (ADHD), and findings have been inconsistent and lacking information on specific causes of deaths. Objective: To investigate the association between ADHD and causes of death in Taiwan. Design, Setting, and Participants: A nationwide population-based cohort study was conducted using a cross-national Taiwanese registry. The ADHD group comprised 275 980 individuals aged 4 to 44 years with a new diagnosis between January 1, 2000, and December 31, 2012. All individuals with ADHD were compared with 1 931 860 sex- and age-matched controls without ADHD. Exposures: The association between ADHD and mortality was analyzed using a Cox regression model that controlled for sex, age, residence, insurance premium, outpatient visits, congenital anomaly, intellectual disability, depression disorder, autism, substance use disorder, conduct disorder, and oppositional defiant disorder. The analysis of suicide, unintentional injury, homicide, and natural-cause mortality was performed by a competing risk adjusted Cox regression controlling for other causes of mortality and potential confounding factors. Main Outcomes and Measures: Data on mortality from all causes, suicide, unintentional injury, homicide, and natural causes collected from a national mortality database. Results: There were 275 980 individuals with ADHD and 1 931 860 comparison individuals without ADHD in this study. Sex and age at index date were matched. The mean (SD) age was 9.61 (5.74) years for both groups. Most of the participants were male (209 406 in the ADHD group; 1 465 842 in the non-ADHD group; 75.88% for both groups). A total of 4321 participants from both cohorts died during the follow-up period (15.1 million person-years), including 727 (0.26%) from the ADHD group and 3594 (0.19%) from the non-ADHD group. Of those who died, 546 (75.1%) in the ADHD group and 2852 (79.4%) in the non-ADHD group were male. After adjusting for potential confounders, compared with the non-ADHD group, patients with ADHD showed higher overall mortality (adjusted hazard ratio, 1.07; 95% CI, 1.00-1.17) and higher injury-cause mortality from suicide (adjusted hazard ratio, 2.09; 95% CI, 1.62-2.71), unintentional injury (adjusted hazard ratio, 1.30; 95% CI, 1.10-1.52), and homicide (adjusted hazard ratio, 2.00; 95% CI, 1.09-3.68). No increased risk of natural-cause mortality was observed after adjustment. Conclusions and Relevance: In this study, ADHD was associated with higher injury-cause mortality, particularly that due to suicide, unintentional injury, and homicide. Although the risk of injury mortality was significantly higher in patients with ADHD than in the non-ADHD group, the absolute risk of mortality was low.

Diagnosed Mental Health Conditions and Risk of Suicide Mortality.

OBJECTIVE: Although mental health conditions are risk factors for suicide, limited data are available on suicide mortality associated with specific mental health conditions in the U.S. population. This study aimed to fill this gap. METHODS: This study used a case-control design. Patients in the case group were those who died by suicide between 2000 and 2013 and who were patients in eight health care systems in the Mental Health Research Network (N=2,674). Each was matched with 100 general population patients from the same system (N=267,400). Diagnostic codes for five mental health conditions in the year before death were obtained from medical records: anxiety disorders, attention deficit-hyperactivity disorder (ADHD), bipolar disorder, depressive disorders, and schizophrenia spectrum disorder. RESULTS: Among patients in the case group, 51.3% had a recorded psychiatric diagnosis in the year before death, compared with 12.7% of control group patients. Risk of suicide mortality was highest among those with schizophrenia spectrum disorder, after adjustment for age and sociodemographic characteristics (adjusted odds ratio [AOR]=15.0) followed by bipolar disorder (AOR=13.2), depressive disorders (AOR=7.2), anxiety disorders (AOR=5.8), and ADHD (AOR=2.4). The risk of suicide death among those with a diagnosed bipolar disorder was higher in women than men. CONCLUSIONS: Half of those who died by suicide had at least one diagnosed mental health condition in the year before death, and most mental health conditions were associated with an increased risk of suicide. Findings suggest the importance of suicide screening and providing an approach to improve awareness of mental health conditions.

ADHD risk genes involved in dopamine signaling and metabolism are associated with reduced estimated life expectancy at young adult follow-up in hyperactive and control children.

ADHD is associated with an elevated risk of mortality and reduced estimated life expectancy (ELE) by adulthood. Reduced life expectancy is substantially related to the trait of behavioral disinhibition; a correlate of both ADHD and of several dopamine genes related to dopamine signaling and metabolism. We therefore hypothesized that several ADHD risk genes related to dopamine might also be predictive of reduced ELE. Using a longitudinal study of 131 hyperactive children and 71 control cases followed to young adulthood, we examined whether several polymorphisms involving DRD4, DAT1, and DBH were related to ELE. The homozygous 9/9 allele of DAT1 and the heterozygous allele of DBH TaqI were associated with 5- and 2-year reductions, respectively, in total ELE. They did not operate on ELE through any relationships to ADHD specifically or behavioral disinhibition more generally. Instead, they showed links to alcohol use (DBH), reduced education, smoking, and reduced exercise (DAT1) employed in the computation of ELE. We conclude that polymorphisms of two dopamine genes are linked to reductions in ELE independently of their association with ADHD.

[Attention deficit hyperactivity disorder beyond adolescence. Time to think different?] / Trastorno por déficit de atención e hiperactividad más allá de la adolescencia ¿Tiempo de pensar diferente?

ADHD is a neurodevelopmental disorder characterized by a pattern of severe inattention-disorganization and/or hyperactivity-impulsivity beyond what is expected for individuals with a comparable development level. These behaviors impair daily life activities of patients in more than one environment and impact their performance and abilities compared with their peers. Extensive reviews have been published about the psychiatric comorbidities associated with ADHD but little attention has been given to the overall impact of ADHD on health. This study reviews some of the most common problems in medical care associated with ADHD like smoking, substance use, accident risk, sleep disorders, obesity, hypertension, diabetes, and early mortality. Today, a close follow-up of patient with ADHD is necessary not only from the psychiatric perspective but also in regard to general medicine issues to prevent the impact on health of those medical co-morbidities. Such conditions can end in severe chronic diseases with consequences and high cost for the individuals, the families and the society far beyond the academic and emotional impact frequently described as associated to ADHD. This condition has serious repercussions on health which need a medical multidisciplinary approach.

Trastorno por déficit de atención e hiperactividad más allá de la adolescencia ¿tiempo de pensar diferente? / Attention deficit hyperactivity disorder beyond adolescence. Time to think different?

El trastorno por déficit de atención e hiperactividad (TDAH) es un desorden del neurodesarrollo caracterizado por un patrón de inatención-desorganización e hiperactividad-impulsividad más grave que lo esperado para el nivel de desarrollo de acuerdo con la edad del individuo. Para el diagnóstico es necesario, además, que este comportamiento produzca alteraciones en las distintas áreas de funcionamiento del afectado en comparación con individuos similares de su entorno. Se han publicado extensas revisiones sobre las comorbilidades psiquiátricas asociadas con el TDAH, pero se ha dedicado poca atención a su efecto en la salud general. En este trabajo se revisan algunos de los problemas de medicina general del adulto más frecuentemente asociados con el diagnóstico de TDAH, tales como tabaquismo, adicción, accidentes, trastornos de sueño, obesidad, hipertensión, diabetes, y muerte temprana. Hoy se requiere un seguimiento más cercano de los afectados con TDAH, no solo desde el punto de vista psiquiátrico sino también en lo referente a la atención médica general, para prevenir su impacto sistémico que en la adultez lleva a enfermedades crónicas graves y costosas para los sistemas de salud, los individuos y la sociedad. Estas consecuencias tienen repercusiones médicas muy serias que exceden lo académico y lo emocional y deben ser consideradas por equipos multidisciplinarios.

ADHD is a neurodevelopmental disorder characterized by a pattern of severe inattention-disorganization and/or hyperactivity-impulsivity beyond what is expected for individuals with a comparable development level. These behaviors impair daily life activities of patients in more than one environment and impact their performance and abilities compared with their peers. Extensive reviews have been published about the psychiatric comorbidities associated with ADHD but little attention has been given to the overall impact of ADHD on health. This study reviews some of the most common problems in medical care associated with ADHD like smoking, substance use, accident risk, sleep disorders, obesity, hypertension, diabetes, and early mortality. Today, a close follow-up of patient with ADHD is necessary not only from the psychiatric perspective but also in regard to general medicine issues to prevent the impact on health of those medical co-morbidities. Such conditions can end in severe chronic diseases with consequences and high cost for the individuals, the families and the society far beyond the academic and emotional impact frequently described as associated to ADHD. This condition has serious repercussions on health which need a medical multidisciplinary approach.

Rates and Patterns of Comorbidity Among First-Year College Students With ADHD.

The purpose of this study was to examine rates and patterns of non-attention-deficit/hyperactivity disorder (non-ADHD) psychiatric diagnoses among a large group of 1st-year college students with and without ADHD. A total of 443 participants, including 214 men and 229 women ranging in age from 18 to 22 years of age (M = 18.2), were recruited from 9 colleges involved in a large-scale, multisite longitudinal investigation. Non-Hispanic Caucasian students represented 67.5% of the total sample. A comprehensive multimethod assessment approach was used in conjunction with expert panel review to determine both ADHD and comorbidity status. Significantly higher rates of overall comorbidity were found among college students with well-defined ADHD, with 55.0% exhibiting at least one comorbid diagnosis and 31.8% displaying two or more, relative to the corresponding rates of non-ADHD diagnoses among Comparison students, which were 11.2% and 4.0%, respectively. These differences in overall comorbidity rates were, in large part, attributable to the increased presence of depressive and anxiety disorders, especially major depressive disorder (active or in partial remission) and generalized anxiety disorder, among the students with ADHD. Within the ADHD group, differential comorbidity rates were observed as a function of ADHD presentation type and gender but not ethnic/racial diversity status. The current findings fill a gap in the literature and shed new light on the rates and patterns of comorbidity among emerging adults with ADHD in their 1st year of college. Implications for providing clinical and support services to college students with ADHD are discussed.

Mortality in individuals with disruptive behavior disorders diagnosed by specialist services - A nationwide cohort study.

Disruptive behavior disorders (DBDs), inclusive of oppositional defiant disorder (ODD) and conduct disorder (CD), are associated with outcomes likely to increase risk of mortality. Using Danish National Registers, a total of 1.92 million individuals including 9495 individuals with DBDs diagnosed by specialist services were followed from their first birthday to 2013. Those with and without DBDs were compared using mortality rate ratios (MRRs) estimated using Poisson regression and adjusted for calendar period, age, sex, family history of psychiatric disorders, maternal age at time of birth, paternal age at time of birth, parental education status, and parental employment status. Over the course of follow up, which totalled 24.9 million person-years, 5580 cohort members died including 78 individuals with DBDs. The mortality rate per 10,000 person-years was 9.66 for individuals with DBDs compared to 2.22 for those with no diagnosis. This corresponded to a fully adjusted MRR of 2.57 (95% confidence interval 2.04-3.20). Comorbid substance use disorder and attention-deficit/hyperactivity disorder resulted in the highest MRR across all categories. These findings demonstrate the excess mortality associated with DBDs.

Attention Deficit Hyperactivity Disorder and adult mortality.

This study examines the relationship between self-reported ADHD and adult mortality over a four-year period, and whether ADHD is associated with underlying cause of death (accidents versus all others). If ADHD increases mortality risk through accidents, then interventions may be designed and implemented to reduce risk and prevent premature death. We estimate descriptive statistics and multivariate logistic regression models using data from the 2007 U.S. National Health Interview Survey (NHIS) Sample Adult File linked to National Death Index (NDI) data through 2011 (N=23,352). Analyses are weighted and standard errors are adjusted for the complex sampling design. We find that the odds of dying are significantly higher among those with ADHD than among those without ADHD net of exogenous sociodemographic controls (adjusted odds ratio=1.78, 95% confidence interval=1.01, 3.12). Although marginally non-significant, accidental death is more common among those with ADHD than among those without ADHD (13.2% versus 4.3%, p=0.052). Few population-representative studies examine the relationship between ADHD and adult mortality due to data limitations. Using NHIS data linked to the NDI, we are only able to observe a few deaths among adults with ADHD. However, ADHD is associated with significantly higher odds of dying for adults and results suggest that accidents may be an underlying cause of death more often for decedents with ADHD. Future research should further examine the mechanisms linking ADHD to adult mortality and the extent to which mortality among persons with ADHD is preventable. Regular measurement of ADHD among adults in the NHIS is warranted.

Long-QT Syndrome and Therapy for Attention Deficit/Hyperactivity Disorder.

INTRODUCTION: Stimulants are the mainstay therapy for attention deficit/hyperactivity disorder (ADHD) and are associated with adrenergic side effects. There are limited data on the clinical course of patients treated for ADHD who have long-QT syndrome (LQTS), for which ß-blockade is the goal of therapy. METHODS: LQTS patients from the Rochester-based LQTS Registry (open-enrollment between 1979 and 2003; follow-up from 1979 to present) treated with stimulant or nonstimulant ADHD medications (n = 48) were compared to a 2:1 age-, gender-, and QTc-duration matched LQTS control group not exposed to ADHD medications (n = 96). Kaplan-Meier and Cox proportional hazards regression analyses were used to evaluate risk of cardiac events (syncope, aborted cardiac arrest, and sudden cardiac death) in LQTS patients treated with ADHD medications. RESULTS: During a mean follow-up of 7.9 ± 5.4 years after initiation of ADHD medication at a mean age 10.7 ±7.3 years, there was a 62% cumulative probability of cardiac events in the ADHD treatment group compared to 28% in the matched LQTS control group (P < 0.001). Time-dependent use of ADHD medication was associated with an increased risk for cardiac events (HR = 3.07; P = 0.03) in the multivariate Cox model adjusted for time-dependent ß-blocker use and prior cardiac events. Subgroup gender analyses showed that time-dependent ADHD medication was associated with an increased risk in male LQTS patients (HR = 6.80, P = 0.04). CONCLUSIONS: LQTS patients treated with ADHD medications have increased risk for cardiac events, particularly syncope, and this risk is augmented in males. The findings highlight the importance of heightened surveillance for LQTS patients on ADHD medications.

Mortality in children, adolescents, and adults with attention deficit hyperactivity disorder: a nationwide cohort study.

BACKGROUND: Attention deficit hyperactivity disorder (ADHD) is a common mental disorder associated with factors that are likely to increase mortality, such as oppositional defiant disorder or conduct disorder, criminality, accidents, and substance misuse. However, whether ADHD itself is associated with increased mortality remains unknown. We aimed to assess ADHD-related mortality in a large cohort of Danish individuals. METHODS: By use of the Danish national registers, we followed up 1·92 million individuals, including 32,061 with ADHD, from their first birthday through to 2013. We estimated mortality rate ratios (MRRs), adjusted for calendar year, age, sex, family history of psychiatric disorders, maternal and paternal age, and parental educational and employment status, by Poisson regression, to compare individuals with and without ADHD. FINDINGS: During follow-up (24·9 million person-years), 5580 cohort members died. The mortality rate per 10,000 person-years was 5·85 among individuals with ADHD compared with 2·21 in those without (corresponding to a fully adjusted MRR of 2·07, 95% CI 1·70-2·50; p<0·0001). Accidents were the most common cause of death. Compared with individuals without ADHD, the fully adjusted MRR for individuals diagnosed with ADHD at ages younger than 6 years was 1·86 (95% CI 0·93-3·27), and it was 1·58 (1·21-2·03) for those aged 6-17 years, and 4·25 (3·05-5·78) for those aged 18 years or older. After exclusion of individuals with oppositional defiant disorder, conduct disorder, and substance use disorder, ADHD remained associated with increased mortality (fully adjusted MRR 1·50, 1·11-1·98), and was higher in girls and women (2·85, 1·56-4·71) than in boys and men (1·27, 0·89-1·76). INTERPRETATION: ADHD was associated with significantly increased mortality rates. People diagnosed with ADHD in adulthood had a higher MRR than did those diagnosed in childhood and adolescence. Comorbid oppositional defiant disorder, conduct disorder, and substance use disorder increased the MRR even further. However, when adjusted for these comorbidities, ADHD remained associated with excess mortality, with higher MRRs in girls and women with ADHD than in boys and men with ADHD. The excess mortality in ADHD was mainly driven by deaths from unnatural causes, especially accidents. FUNDING: This study was supported by a grant from the Lundbeck Foundation.

Long-term outcomes of pharmacologically treated versus non-treated adults with ADHD and substance use disorder: a naturalistic study.

BACKGROUND AND AIMS: The pharmacological treatment of individuals with attention deficit hyperactivity disorder (ADHD) and severe substance use disorder (SUD) is controversial, and few studies have examined the long-term psychosocial outcome of these treatments. Our aim was to investigate whether pharmacological treatment was associated with improved long-term psychosocial outcomes. METHODS: The present naturalistic study consisted of a long-term follow-up of 60 male patients with ADHD and comorbid severe SUD; all participants had received compulsory inpatient treatment due to severe substance abuse. The average interval between inpatient discharge and follow-up was 18.4 months. Thirty patients had received pharmacological treatment for ADHD, and 30 patients were pharmacologically untreated. The groups were compared with respect to mortality and psychosocial outcomes operationalized as substance abuse status, ongoing voluntary rehabilitation, current housing situation and employment status. RESULTS: The groups were comparable with regard to the demographic and background characteristics. Overall, mortality was high; 8.3% of the participants had deceased at follow-up (one in the pharmacologically treated group and four in the untreated group; the between-group difference was not significant). The group that received pharmacological treatment for ADHD exhibited fewer substance abuse relapses, received more frequently voluntary treatments in accordance with a rehabilitation plan, required less frequent compulsory care, were more frequently accommodated in supportive housing or a rehabilitation center, and displayed a higher employment rate than the non-treated group. CONCLUSIONS: The recommendations for the close clinical monitoring of high-risk populations and the prevention of misuse and drug diversion were fulfilled in the structured environment of compulsory care for the treated group. Pharmacological treatment of ADHD in individuals with severe SUD may decrease the risk of relapse and increase these patients' ability to follow a non-pharmacological rehabilitation plan, thereby improving their long-term outcomes.