Conference Agenda

(Meth)amphetamine use disorders (MAUD) are increasing substantially, and are associated with increased risk of morbidity and mortality. However, there are no medications approved by authorities for the treatment of amphetamine or methamphetamine dependence, and studies investigating the effectiveness of pharmacological treatments in hard outcomes, such as hospitalization and death, are lacking. Also, borderline personality disorder (BPD) has no established pharmaceutical treatment, even though BPD affects about 1%–2% of the general population. Nevertheless, up to 94% of patients with BPD receive psychotropic medication.

The current knowledge of the effectiveness of pharmacological treatments of MAUD and BPD is largely based on randomized controlled trials (RCTs). RCTs provide information on the efficacy of treatments in standardized settings in selected patient populations, i.e. they tell us if the treatment can work in optimal conditions. Observational studies can inform us about the effectiveness of drugs, indicating whether or not these treatments actually work in a real-life setting. Both of these approaches (RCTs and observational studies) have their pros and cons. In RCTs, randomization eliminates the selection bias, which is a problem in observational studies. On the other hand, highly selected patient populations, limited number of participants, and relatively short follow-up periods in RCTs make it very difficult to study relatively rare outcomes such as death, suicide, or severe adverse effects of medications. Using large unselected nation-wide patient cohorts can overcome these obstacles.

Nordic countries with comprehensive nation-wide registers provide good possibilities for pharmacoepidemiological research. During the last decade, within-individual analysis has been utilized increasingly to eliminate selection bias related to time-invariant characteristics, such as sex, genetics, and initial severity of illness. This research has increased the knowledge on the effectiveness of the pharmacological treatments, for example in schizophrenia, and has contributed to national treatment guidelines in several countries. This lecture will review how the big data have provided new insights to the associations between various pharmacological treatments and mortality and hospitalizations among patients with MAUD and BPD. Especially the ADHD-medication lisdexamphetamine have shown some promising results in reducing mortality, hospitalizations and suicides among persons with either MAUD or BPD. In the cohort of nearly 14 000 persons with MAUD, lisdexamphetamine was associated with reduced risk of hospitalization due to substance use disorders, any hospitalization or death and all-cause mortality. In the other study, concerning the cohort of over 17 500 persons with BPD found that the use of lisdexamphetamine was associated with reduced risk of psychiatric hospitalizations and all-cause hospitalization or death. The use of lisdexamphetamine was also associated with reduced risk of attempted or completed suicide in the cohort of over 22 000 persons with BPD.

Background

Treatment with stimulants is considered the most efficacious treatment for ADHD. Large high-quality studies have estimated the prevalence of AHDH to be 3,4-7,2% for children and adolescents and 2,5-6,8% for young adults. Psychosis and manias are rare but serious side effects of ADHD medications.

Objectives

The aim of this study was to estimate the prevalence of ADHD in Iceland based on ADHD drug prescriptions as well as the risk of hospitalization for first-onset psychosis or mania among adults prescribed ADHD drugs in Iceland.

Materials and Methods

Every citizen receiving a medication prescription is included in the Icelandic Prescription Medicines Registry (IPMR). When assessing the prevalence of ADHD diagnosis, the study included all Icelanders 7-70 years old who received a prescription for an ADHD medication from 1.1.2004-31.12.2023. The risk of psychosis or mania was estimated for adults who were hospitalized within a year after initiation of ADHD drug therapy. To identify individuals who were admitted to hospitals due to psychosis or mania records were linked from the Icelandic Prescription Drug Register to the Icelandic Hospital Discharge Register. There was full access to all relevant hospital records.

Results

In 2023 14,7% of youth, 7-17 years of age, received a prescription for an ADHD medication, 17,7% of boys and 11,6% of girls. For 18-44 years old adults the proportion was 10,2%, 9,4% for males and 11,0% for girls. The incidence of new ADHD prescriptions for 7-17 years old boys from 2021-2023 was 10,9 and 13,5 for girls per 1000, respectively. For 18-44 years old the incidence in the years 2021-2023 was 18,7 for males and 19,2 for females per 1000, respectively.

16,125 individuals 18 years or older initiated ADHD drug therapy from 2010-2022 and 112 were admitted for psychosis or mania within a year of commencing treatment. Of these 61 (54.5%) were hospitalized due to first-onset psychosis or mania, 48 for psychosis and 13 for mania. This corresponds to an estimated absolute risk of 0.38% for first-onset psychosis or mania. Within one year of hospital discharge, 42 of 61 patients had been represcribed an ADHD drug.

Conclusion

The prevalence of Icelanders who have received an ADHD diagnosis is much higher than is observed in larger studies elsewhere. One out of every 264 (0,38%) adults that initiated ADHD drug therapy was hospitalized due to first-onset psychosis or mania within one year of starting ADHD medication .

Introduction The use of medications for attention-deficit/hyperactivity disorder (ADHD) has grown significantly in recent decades. Yet, the long-term cardiovascular risks linked to these medications are not well understood.

Methods A nationwide, nested case-control study was conducted using data from individuals aged 6 to 64 diagnosed with ADHD from 2007 to 2020, through the linkage of various Swedish national databases. The study measured the cumulative duration of ADHD medication use, with a maximum follow-up of 14 years from pharmacy records. The main variable of interest was the occurrence of new-onset cardiovascular diseases (CVDs). Risk association was analysed by calculating adjusted odds ratios (ORs), with their 95% confidence intervals (CIs).

Results The study included 278,027 ADHD patients, identifying 10,388 CVD cases and 51,672 matched controls. The median participant age was 34.6, and 59.2% were male. The median duration of follow-up was 4.1 years. Results indicated a higher CVD risk with longer ADHD medication use compared to no use. Across the 14-year follow-up, a one-year increase of ADHD medication use was associated with a 4% increased risk of CVDs on average (OR, 1.04 [95% CI, 1.03-1.05]), with the increase in risk being more pronounced in the first 3 years of cumulative use (one-year OR, 1.08 [95% CI, 1.04-1.11]) and stable over the remaining extended follow-up. This risk was primarily attributed to hypertension and arterial disease. Both children/adolescents and adults showed similar risk patterns.

Conclusion Long-term use of ADHD medications is associated with heightened CVD risk, particularly for hypertension and arterial diseases. These findings underscore the need for careful risk-benefit assessment in long-term ADHD medication therapy and consistent monitoring of cardiovascular health throughout treatment.