Men with ADHD in compulsory care for substance abuse : characterization and treatment

Abstract: Substance use disorder (SUD) is one of the most common comorbid conditions in adults with attention deficit-hyperactivity disorder (ADHD). There are still few studies that address combined ADHD and SUD as compared to studies on ADHD without SUD. The aims of the present thesis were (1); to conduct a clinical characterization of men with ADHD in compulsory care for severe SUD; (2) to investigate whether pharmacological treatment in ADHD/SUD cases was associated with improved long-term psychosocial outcomes; (3) to explore the feasibility of DBT (dialectic behavior therapy)-based skills training in ADHD/SUD patients in compulsory care; and (4) to explore the association between the skills training and the psychosocial outcome after six months. All studies were conducted at a compulsory care institution for men. In the clinical characterization (Study I), 60 men with ADHD and SUD were compared with (1) 120 men in compulsory care for severe substance abuse without a known ADHD regarding comorbid psychiatric symptoms, psychosocial background, treatment history, and cognition, and with (2) 107 men with ADHD but without severe SUD from an outpatient psychiatric clinic. In Study II, a comparison was made between 30 patients who had received pharmacological treatment for ADHD and 30 non-treated patients. The long-term outcome was measured as the current status regarding abuse, voluntary rehabilitation, accommodation and employment, as well as mortality. In Study III, the feasibility and acceptability of DBT- based skills training were explored; 40 patients were included. The patients were follow-up six months after discharge from compulsory care, (Study IV). The outcome measures were substance abuse status, voluntary treatment status, and accommodation and employment status. The characteristics of the ADHD/SUD found in Study I were an early onset of antisocial behavior that persisted into adulthood and poor cognitive skills. Study II showed that the overall mortality was high (8.3%) and that the pharmacologically treated group had significantly better outcomes in all measured psychosocial parameters. In Study III, it was found that the DBT-based skills training for ADHD was feasible and acceptable in a context of compulsory care for SUD. Significant symptom reduction, as well as an increased general well-being, was also found. The completers of the DBT-based skills training had fewer relapses and were more often in voluntary treatments, compared to non-completers in the six-month follow-up study (Study IV). However, no causal conclusion regarding the relationship between the DBT-based skills training and the psychosocial outcome can be drawn due to the base-line differences between completers and non-completers, as well as the lack of a control group. To sum up, ADHD in combination with SUD is a particularly disabling condition. The combination of severe substance abuse, poor general cognitive ability, severe psycho-social problems, including indications of antisocial behavior, and other co-existing psychiatric conditions should be considered in treatment planning for adults with ADHD and SUD. Pharmacological treatment of ADHD in individuals with ADHD and severe SUD may decrease the risk of relapse and increase the patients’ ability to follow a nonpharmacological rehabilitation plan and thereby improve their long-term outcomes. Use of the structured treatment setting in the compulsory care for SUD for the initiation and stabilization of the pharmacological treatment for ADHD may be beneficial for high-risk populations. Furthermore, adapted structured treatments, such as DBT-based skills training, may be feasible in compulsory care and useful for some patients in this group. Discontinuation of voluntary treatment programs during the compulsory care may indicate low motivation or ability to participate in voluntary treatment and therefore predict a negative outcome after discharge.