INTRODUCTION
Attention Deficit Hyperactivity Disorder (ADHD) is one of the most frequent neuropsychiatric disorders of childhood. Recent studies have shown that ADHD is not limited to childhood but also continued in the adulthood. ADHD, which is diagnosed in childhood, is reported to have a continuation rate of 65% in adulthood (1). 15% of these cases fulfill all criteria for diagnosis, while 50% meet some criteria (1). In our country, it is reported that the prevalence of adult ADHD was between 1.6-15.9% in the psychiatric outpatients (2,3). In a recent epidemiological study, the prevalence of ADHD was found as 3.8% (4). The results of the researches reported in literature make us think that ADHD could be evaluated as an on-going, neurodevelopmental disorder, whose effects last lifelong, leads to indirect costs other than treatment costs and results in lifelong disability in affected individuals (5,6).
ADHD and major depressive disorder (MDD) comorbidity was shown in both clinical and epidemiological studies (7,8). In an epidemiological study carried out by Kessler et al. (8), the prevalence of MDD was reported as 18.6% in individuals, who were diagnosed with ADHD, while it was determined as 7.8% in individuals who were not diagnosed with ADHD. The prevalence of lifelong MDD was reported as high as up to 63% in adult ADHD in clinical studies (9). The studies which evaluate the prevalence of ADHD in adult outpatients in our country show that these patients mostly applied because of depressive complaints in which irritability was dominant and the most frequent co-diagnoses were dysthymic disorder and MDD (2,3,10).
Although ADHD diagnosed in childhood is rather prominent in men (11), recently obtained data show that ADHD diagnosis in women in adulthood was higher than previously supposed (12). Emotional symptoms, sleep disorders, anxiety symptoms and depressive symptoms were more frequently determined in women, who were diagnosed with ADHD when compared to men (13). ADHD diagnosis is a substantial risk factor for MDD. This risk may be more obvious in the female gender. A five-year follow-up study in which girls with ADHD were followed until the adolescence and adulthood showed that MDD risk increased 2.5 times in these patients (14). Other follow-up studies in ADHD have also reported that comorbidity of MDD and anxiety disorders were higher in women when compared to men in young adulthood. While the ratio of anxiety disorders in women with ADHD tends to show no substantial change after 25 years old, the ratio of mood disorders continue to increase between 25-30 years old (15). The diagnosis of ADHD is usually unrecognized in women with ADHD who apply with depressive complaints, and this leads to a treatment plan targeting only MDD in these patients (12). Kessler et al. (8) reported that only one-fourth of the adults diagnosed as ADHD who sought for psychiatric treatment in the last 12 months received treatment for ADHD in general population. ADHD diagnosis is related to low academic success, divorce, unemployment, frequent changes in job, low socioeconomic status in adult life (16-18). ADHD and MDD comorbidity results in more severe psychosocial dysfunction (14,19).
In the literature specific to our country, no researches have been found to evaluate the prevalence of ADHD in adult female outpatients with depressive complaints. It has been reported that MDD risk was significant in women with ADHD diagnosis, and although depressive symptoms are diagnosed and treated, ADHD diagnosis remained unrecognized (12,14). ADHD comorbidity can also influence the severity and progress of MDD (14). In the light of this information, this study aimed to determine the prevalence of ADHD symptoms and diagnosis among adult female patients who referred to the outpatient clinic and diagnosed with mild-moderate MDD based on DSM-IV-TR criteria and Clinical Global Impression (CGI) as well as to evaluate the relationship between symptoms of ADHD and MDD.
METHOD
Sample
Sixty one female patients who were older than 18 years and examined for the first time in Kocaeli Derince Training and Research Hospital Psychiatry Outpatient Clinic between June 2008 and July 2009 and diagnosed as having MDD based on DSM-IV-TR criteria, were enrolled in the study. MDD severity was mild-moderate according to Clinical Global Impression Scale (CGI-S) and none of the patients had Axis I comorbidity. The patients who applied to the outpatient clinic for the first time, who did not receive any treatment at that time for their current (index) depressive episode were taken into the study. There were no patients who rejected to participate in the study. Those with organic brain disease history which may disrupt cognitive functions such as head trauma, epilepsy were excluded, and patients having at least 5 years of education were included in the study.
After taking the informed consent of the patients, their sociodemographic data and past treatment histories were questioned, and the patients were applied Hamilton Depression Scale (HAM-D). The patients were called for routine outpatient controls. In the event that the evaluations to be made in the symptomatic periods of the disorders may influence the responses (20), patients were applied Wender-Utah Rating Scale (WURS), when they were in remission (HAM-D score ≤7), the patients who were above the cut-off score were applied Adult Attention Deficit Hyperactivity Rating Scale (A-ADHRS) and semi-structured interview based on the listed DSM-IV criteria for ADHD. Adult ADHD diagnoses were made according to the availability of DSM-IV criteria such as at least some symptoms should be started before seven years old, ADHD symptoms must be present except for mood state periods from childhood till adulthood and ADHD symptoms must lead to disruption in functionality. The diagnoses were based on patient interviews.
Measures
Hamilton Depression Rating Scale (HAM-D): It is a scale which was developed by Williams, (21) and of which Turkish validity and reliability were performed by Akdemir et al. (22). It is applied by the clinician, and measures the level of depression and changes in severity.
Wender-Utah Rating Scale (WURS): It is a Likert type self-rating scale which was developed in 1993. Turkish validity and reliability of WURS was performed by Oncu et al. (20). It questions the presence and severity of childhood ADHD symptoms. The scores of the scale ranges between 0-100, and the cut-off score is recommended as 36 by the authors who translated it into Turkish.
Adult Attention Deficit Hyperactivity Rating Scale (A-ADHRS): It is a Likert type, 30-question scale which was developed by Turgay (23), and of which validity and reliability study was performed by Gunay et. al (24). The scale consists of three parts, which are attention deficit, hyperactivity/impulsivity and the issue questioning ADHD associated emotional and behavioural symptoms. It was put forth that the scale is a useful scale which has high sensitivity and specificity, and can be used in the diagnoses, treatment and researches of adult ADHD.
Statistical Analysis
Statistical analysis were made by using SPSS (Statistical Package for Social Sciences) 16.0 package program. Quantitative data was specified as average and standard deviation.
Nonparametric test, Mann-Whitney U test was used in the comparison of two groups’ average for constant variables; and Spearman correlation test was used in the evaluation of the correlations. The significance value was considered as p<0.05 in the analyses.
RESULTS
Most of the participants were married (59%, n=36) and housewives (49.3%, n=30). When the marital status of the patients was evaluated, it was seen that 32.5% (n=20) were single, 5% (n=3) were widowed, 3.3% (n=2) were divorced. While 18% (n=11) of the patients were employed, 14.7% (n=9) were students, and 8.2% (n=5) were unemployed. The mean age was 30.72±6.73 (range:18-44), mean education level was 8.90±3.75 years (range:5-15). First episode depression was determined in 59% (n=36) of the patients (range for number of episodes: 1-4).
WURS scales were determined as 36 and above in 31.1% (n=19) of the research group. When these persons were evaluated by A-ADHRS and semi-structured interview based on DSM-IV criteria, four persons (6.5%) met the diagnostic criteria. Compound type ADHD was determined in three patients and attention deficit type was determined in one patient. No differences were found between those who received above the cut-off score from WURS and other patients according to the mean education level, number of episodes, treatment duration of the last episode and first HAM-D scores (Table 1). No significant difference was observed according to the mean education level, age, number of depressive episodes, duration of the last treatment, WURS scores and the first HAM-D scores between the patients, who received above the cut-off score from WURS but did not receive adult ADHD diagnosis and those who met adult ADHD diagnosis criteria according to A-ADHRS and DSM-IV criteria (Table 2).
No significant correlation was determined among mean education level, age, number of episodes, treatment duration of last episode, WURS scores and the first HAM-D scores in those whose WURS scores were above the cut-off score (p>0.005).
DISCUSSION
The aim of the study was to determine the prevalence of ADHD symptoms and diagnosis and factors associated with the symptoms in adult female patients who had MDD diagnosis and had no comorbidity according to DSM-IV-TR criteria and applied to the psychiatry outpatient clinic of a training hospital for the first time.
In our study, the rate of childhood ADHD symptoms determined with WURS in women with MDD was 31.1%, while the rate of adult ADHD which meets diagnostic criteria with DSM-IV criteria and A-ADHRS was determined as 6.5%. Duran (2) reports the rate of childhood ADHD determined with WURS in patients, who applied to adult psychiatry outpatient clinic as 30.5%. Tamam et al. (25) reported that the rate of childhood ADHD was 27%, the rate of adult ADHD was 16% in their study on bipolar patients. In another study conducted on MDD diagnosed adult patients, it was found that 16% of the patients met complete or sub threshold childhood ADHD criteria while ADHD symptoms still continued in 12% of the patients (26). Therefore, it can be said that our results are compatible with the rates reported for adult psychiatry patients in our country. Although our sample is small, our results make us think that ADHD diagnosis should be kept in mind in women with MDD. Since hyperactivity, disruptive behaviours in childhood ADHD are more obvious in male children, these children are more easily noticed and referred to treatment by their parents or teachers, and this results in about ten times higher male prevalence in pediatric clinic sample (27,28). In adulthood, women seek for help by themselves, and the gender distribution becomes more balanced in adult clinic sample (28).
Studies on explaining ADHD and MDD association claim that there is a familial link between these two disorders. As a result of the data obtained from adoption studies and high-risk families, it was implicated that ADHD and MDD may be different expressions (phenotypes) of a common etiology (genotype) (29). Psychosocial studies reported that factors such as depression in mothers, conflict between parents, parent behaviour management, and control focus can be risk factors for ADHD-MDD association (30,31).
It is reported that gender is effective on the familial association between ADHD and MDD. It is claimed that family members of men with ADHD diagnosis share the familial risk factors of ADHD and MDD, but the non-familial risk factors mediate the onset of ADHD and MDD. It is supposed that ADHD and MDD comorbidity in families of the women with ADHD diagnosis is etiologically different familial subtype of ADHD (32). Future follow-up studies considering sociocultural and genetic factors may provide further data in these issues.
In our research sample, it was determined that those meeting ADHD diagnosis in adulthood were mostly in compound type ADHD. The prevalence of compound type ADHD is reported to be more frequent in clinical sample (33). While attention deficit was determined to be most prevalent type in one of the researches conducted with outpatients in our country, compound type ADHD diagnosis was determined to be prevalent in the other (2,3). Upon evaluating the available data, it could be said that the information is insufficient with regard to whether the ADHD subtypes varied based on the diagnosis of adult psychiatry outpatients and there is a need for further additional researches.
The effects of ADHD comorbidity on MDD were reported. Biederman et al. (14) indicated that MDD begins earlier, lasts longer, and is more severe and relates to suicide attempts and hospitalization in women with ADHD. No difference was determined in our study and this might be related to the fact that the sample group was consisted of mild-moderate MDD patients followed-up in outpatient clinics. The small sample size might also have influence on this.
The most important limitations of our study are that it is cross sectional, focuses on patients with mild-moderate depressive episode, comorbidities are not excluded with structured interviews, no information was received from the families, relatives and employers of the patients about childhood and adult ADHD diagnoses. Since our data is based on the evaluation of the female outpatients with MDD diagnosis, it is not possible to generalize our results to the female patients who have more severe complaints and comorbidities and receive in-patient treatment. Further studies evaluating such points might present different information about MDD-ADHD association.
Despite all limitations, it can be said that ADHD diagnosis was not rare in women who applied to an adult psychiatry outpatient clinics with depressive complaints and were diagnosed with MDD based on DSM-IV-TR criteria. The recognition of MDD-ADHD association in these patients will facilitate handling the patients with these two disorders requiring different treatment approaches.
