Mortality in People with ADHD [pdf] | Hacker News Reader

Mortality in People with ADHD [pdf]

nice.org.uk

42 pointsDanBC35 comments

    All-cause mortality was 5.85 per 10,000 person–years among people 
    with ADHD, compared with 2.21 per 10,000 person–years in people without ADHD. The risk of death 
    among people with ADHD was more than double that in the general population (adjusted mortality rate 
    ratio [MRR]=2.07, 95% confidence interval [CI] 1.70 to 2.50, p<0.0001).

They then give the mortality rates for those diagnosed with ADHD another disorder or substance misuse issues:

    Age at diagnosis of ADHD was associated with mortality, with the risk of death highest among people 
    diagnosed in adulthood (adjusted MRR=4.25, 95% CI 3.03 to 5.78). Mortality among people with ADHD 
    was also affected by comorbid oppositional defiant disorder or conduct disorder (adjusted MRR=2.17, 
    95% CI 1.33 to 3.31) and by coexisting substance misuse (adjusted MMR=5.63, 95% CI 3.69 to 8.16). 
    Among people without these comorbid conditions, mortality was higher in girls and women with ADHD 
    (adjusted MRR=2.85, 95% CI 1.56 to 4.71) than in boys and men (MRR=1.27, 95% CI 0.89 to 1.76).

The part I found interesting here, that they don't seem to mention elsewhere in this article, is that the mortality rate for males with ADHD but without the other disorders is actually lower than their general population numbers (2.07 general population vs 1.27 for males without one of those issues). They actually seem to completely ignore it:

    “Even if these complications did not develop, ADHD was still a risk factor for mortality. This could well be 
    because the core problem of impulsiveness is a cause of accidents, and accidents were the major cause 
    of death.

I'm going by the adjusted mortality rate ratio number. If I'm reading this wrong, please let me know.

> (2.07 general population vs 1.27 for males without one of those issues)

Since substance misuse and the other disorders influence mortality rates of the ADHD population, it is not surprising that they affect mortality in the general population.

For the inference you seem to be making, I think you would need the mortality rate of males with no ADHD AND no substance misuse/etc. Based on the data given, I see no reason to think that is above 1.27.

I'm just going to requote those excerpts with flowing text:

All-cause mortality was 5.85 per 10,000 person–years among people with ADHD, compared with 2.21 per 10,000 person–years in people without ADHD. The risk of death among people with ADHD was more than double that in the general population (adjusted mortality rate ratio [MRR]=2.07, 95% confidence interval [CI] 1.70 to 2.50, p<0.0001).

Age at diagnosis of ADHD was associated with mortality, with the risk of death highest among people diagnosed in adulthood (adjusted MRR=4.25, 95% CI 3.03 to 5.78). Mortality among people with ADHD was also affected by comorbid oppositional defiant disorder or conduct disorder (adjusted MRR=2.17, 95% CI 1.33 to 3.31) and by coexisting substance misuse (adjusted MMR=5.63, 95% CI 3.69 to 8.16). Among people without these comorbid conditions, mortality was higher in girls and women with ADHD (adjusted MRR=2.85, 95% CI 1.56 to 4.71) than in boys and men (MRR=1.27, 95% CI 0.89 to 1.76).

“Even if these complications did not develop, ADHD was still a risk factor for mortality. This could well be because the core problem of impulsiveness is a cause of accidents, and accidents were the major cause of death.

After losing my passport three weeks ago for the third time (together with a brand new MacBook I bought a few days earlier) and dooming myself to months of documents recovery in two countries I live in, yes, I sometimes just want to f* die.

Life with ADHD is hard.

I feel you. Wishing you luck!

FWIW, some credit cards (at least in the US) have loss protection for recent purchases made on them. Might be worth checking into.

Also everyone I know with ADHD, myself included, goes really really fucking hard at parties and substances. To the point where we put our bodies at massive risk. I'm working at trying to train out the stupidity but it's hard.

Well, I am not much of a partygoer, and the only substances are take is my ADHD prescription drugs (which are bona fide "substances", so I doubt I need anything else among these lines).

I don't have that issue and never have. But my impulse control is often poor - it's pretty freaking awful. Luckily for me it just means I tend to say too much, although this can have devastating consequences.

Yes, impulsive, creative, wild, dangerous, bored people doing riskier things have 2x mortality. There's a lot of things that'll increase it a lot more -- like different geolocations.

I agree that this shouldn't be a surprise. What I'm more interested in is whether the medication used to treat ADD/ADHD could have an adverse health effect that would reduce lifespan, i.e. if they ignore accidental deaths completely, will those on ADD/ADHD meds live just as long as those that do not take those meds?

For stimulants: increased blood pressure. I've had to switch several times because I wasn't able to get to an effective dose without sitting firmly in prehypertension bp levels.

True, although--if this isn't obvious--this won't necessarily matter if you're not prone to high blood pressure. I've got several risk factors as well as ADHD, but even with daily stimulants my blood pressure is comfortably within the healthy range.

Right, and even then.... I now don't have the impulse to go get soda and snack food at the convenience store nearby to kill time. I also find it easier to plan meals and follow through. So, net positive as far as lifespan.

A thing with this study is that they measure survival mostly in an age bracket with relatively low chance of death, but also in a bracket where chances of death by accidents due to lifestyle are relatively high.

A base death rate of 2.2 per 10k years is one per 4500 years. Since you live about 80 years, the sample is skewed towards the not-so-likely to die. Perfectly acceptable btw, but it makes inferences to what happens to the life expectancy Curve harder.

My prior would be: the cumulative survival curve for ADHD is markedly lower in the ages 5-30s (one dies more often when at risk due to accidents), and then converging to the curve UNLESS the medicines are harmful as well.

My point in other words: aMRR is a fine measure, but you really want to identify causes to shifts in (parts of) the survival function. For now it's a finding that just confirms prior beliefs.

[edit] Confirmation by the same author [1]. All that would be cool now is estimates of survival functions. They must have some people in their dataset dying of old age.

"Children with ADHD had an increased risk of injuries compared with other children. Treatment with ADHD drugs reduced the risk of injuries by up to 43% and emergency ward visits by up to 45% in children with ADHD. Taken together with previous findings of accidents being the most common cause of death in individuals with ADHD, these results are of major public health importance."

[1] http://pure.au.dk/portal/en/persons/soeren-dalsgaard(9da0473...

I think I probably have ADHD, and this didn't surprise me. One of the symptoms appears to be a problem with executive function where there's a disconnect between recognizing risk and taking appropriate action to mitigate it. So many times I find myself cursing my stupidity when some foreseen accident actually ends up happening. Fortunately, as you might have already assumed, it hasn't been fatal yet.

> I think I probably have ADHD

Do not think, know. Get checked and officially diagnosed. Otherwise, you are doing yourself and others harm. We test code, we should test ourselves.

I've been looking into it, but it looks like it's going to cost several hundred dollars, which would be fine if I knew I was getting something out of that, but it's a lot of money just to be told, "No, it must be something else."

You will.

Well, true, any information is useful, I guess.

Note that all a psychiatrist does for adults to determine whether they have ADHD is give them a self-reporting questionnaire. You can find sample questionnaires and diagnostic criteria for interpreting them in a couple of places online. In other words, if you're honest with yourself when you answer, you can know exactly what a psychiatrist will say without having to go.

The one thing that might not be mentioned on such sites is that people being tested for ADHD are also given an inventory for anxiety disorders, sometimes mixed into the ADHD questions. Anxiety looks like ADHD in some ways but is treated differently; effectively, in order for an ADHD diagnosis to "count", you have to be not-overly-anxious.

You sure on that? It's extremely common for ADHD to be comorbid with anxiety. There's a challenge in figuring out which is secondary to which, sure (same with depression and ADHD or depression and anxiety--they all confound each other) but I've never heard of apparent anxiety being a disqualification.

Not a disqualification, no; it's more, like you said, that they confound one-another, but usually it's the anxiety doing more of the confounding. It's very hard to determine whether the ADHD really "exists" as its own thing or not until you've treated for the anxiety. (In neurochemical terms, since adrenaline production consumes dopamine, there's no way to know what the person's "normal" dopamine flow is like until you can get them to stop being so stressed out.)

Couple this with the fact that a good few of the psychiatrists I know basically only treat adult ADHD cases—they're easy, no long-term maintenance therapy needed!—and it starts to look more like having anxiety is a "disqualifier". What it really means, though, is that the patient will have to get the anxiety under control before a sensible psychiatrist will trust the calibration of the ADHD self-assessment criteria.

In my case I had to take two questionnaires (one was 100+ questions for general mental disorder evaluation), a subset of an IQ test, and a computer test. The computer test was interesting... it was along the lines of left click when you see the number 2, right click when you hear a sound. No other distractions trying to trick you into clicking, but it is a 15 minute test. Excruciatingly boring, but even trying as hard as I could, the psychiatrist wondered if I had cheated/fudged the test because my results were so far out of whack compared to the IQ test.

It's a muddy situation but your insurance may cover the cost. I explicitly called my insurance provider and asked if they cover the testing required and they said learning disorders weren't covered for adults at all. It was getting to be a big enough issue that I was willing to part with the money out of pocket so I got tested anyways. Insurance ended up paying 100% :/

> Get checked and officially diagnosed.

That can be a surprisingly difficult process.

For example the NHS isn't entirely sure how to diagnose ADHD in adults. My GP didn't even know it was possible, and had to go and make phone calls to find out where the nearest specialist was. Unfortunately if your answer to "Did you get bad grades at school?" is "Not really" then hard luck, as they want evidence of underachievement as a kid to confirm the diagnosis. And there really is no way to complain your above average grades were underachievement without sounding like a dick.

It wasn't until I was in the final stage of my degree that somebody noticed that I had problems, and luckily the University helped me get a private diagnosis for some of my issues.

There are standard batteries of tests now. I'd be surprised if they were completely unknown. The need for evidence back into childhood does probably remain, but I think most pros who understand ADHD know that grades are only one possible indicator.

That's especially true for gifted people (guessing from your "sounding like a dick" sentence), where "twice exceptionality" can be tough to recognize due to smarter people being able to find better coping mechanisms. That particular issue is not unique to ADHD, comes up with dyslexia and other learning difficulties too.

Admittedly my last interaction with the NHS was three years ago, but the GP had to go away and research what to do. I have no problem with that, they can't be expected to know everything offhand! The human mind is a complex thing.

My own hangups make it difficult as I find the whole thing hard to talk about. I have no reason to complain in the grand scheme of things, "Some people have real problems!"

I agree that getting an assessment for ADHD in the NHS is frustrating and too hit or miss.

NICE is aware of that, and they're pretty clear about what should happen.

For anyone living in England: https://www.nice.org.uk/guidance/cg72

I started with the process of getting a diagnose less than a year ago, and am next month meeting up with doctor nr 4 and 5. It is a long and painful process.

I think the vocabulary we use is starting to rub up against its limitations in problematic ways. Medicine is ver geared towards a pathology-diagnosis-treatment paradigm.

When it comes to something like blood pressure that's decent enough. Blood pressure above a certain threshold significantly increases the risks of XYZ and therefore… There are edge cases and grey areas that come from drawing a circle around anything that doesn't naturally conform to categorization, but the paradigm works.

For other things, the paradigm is clunkier. For one thing, doctors have an ethical (and legal, institutional..) objection to intervention unless some "pathology" criteria has been met. Since people want to use treatment and/or sell it, the definition of the pathology is constantly being messed with to conform.

Consider viagra. According to some, it is a pathology in young men but natural in older men. In any case, viagra is allowed to be prescribed. But then, impotence is on a scale. You are not allowed to use the drug unless you fall within some diagnostic parameters. There is no framework for "elective" use. You 22 year olds cannot have it. But, it's probably less harm to a robust 22 year old then a 55 year old.

Anyway, ADHD is something that tends to be diagnosed in children when they exhibit some problematic behavior, usually problematic to schools and sometimes at home. It sticks as a diagnosis when the treatment works.

So, your sample here is largely kids that had behavioral problems for which some sort of intervention (ritalin, meditation, diet..) was sought.

It's almost like saying teenagers expelled for drinking at school are more likely to default on rent in their 40s. It might mean that drinking during formative years affects your financial responsibility, but it probably means that teenager who get into trouble often grow into adults who get into trouble.

I was with you until the last line:

> but it probably means that teenager who get into trouble often grow into adults who get into trouble.

I don't need to be the one to disprove it because the loose terminology is just so ludicrous. You're clumping ADHD in with sooo many other outside factors that influence what is 'trouble' and it's causes.

My mother always warned me to maintain focus or I will walk in front of a bus. Yet she denies to this day I have ADHD (would make her look bad???). After a lifetime thus far of poor coordination, constantly losing things, awkward social interaction and rarely finishing projects, I've come to terms with it. ADHD is associated with risky driving, dangerous misuse of power tools, other 'short cut' behaviors that undermine safety of adhd people and those around them. It IS a public health issue for that reason yet awareness is low.

My anxiety levels are off the charts and I sometimes have suicidal thoughts. I wonder how many ADHD people commit suicide?

If nothing else, I hope that studies like this help people to realize that ADHD is a real thing.

Reply on news.ycombinator.com