Quality of life in adult patients with ADHD and substance use disorder

Introduction

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder whose core symptoms are represented by inattention, hyperactivity and impulsivity inconsistent with the level of development and which causes important functional impairment in the academic, professional and social areas. Recent studies estimate the global prevalence of ADHD at 8%⁽¹⁾, the number of cases in adulthood being represented not only by those that persist from childhood, but also by those newly diagnosed in late adolescence or early adulthood⁽²⁾.

Over 60% of patients diagnosed with ADHD will meet the criteria for a comorbid disorder⁽³⁾. The profile of comorbidities changes according to the age of the patients. Neurodevelopmental and externalization disorders are the most diagnosed comorbidities in childhood, while substance abuse, affective and personality disorders are more common in adulthood⁽⁴⁾.

Substance use disorder (SUD) is characterized by a dysfunctional pattern that persists despite numerous cognitive, behavioral and physiological symptoms resulting from the addictive behavior. Poor control of consumption, accompanied by the desire to stop it, craving, tolerance and withdrawal are central characteristics of SUD⁽⁵⁾. As detailed below, the adolescent brain is susceptible to the development of addictions due to the decreased ability to analyze the risks and benefits of different situations, as well as the need for more intense stimulation of reward centers compared to adults. The presence of ADHD doubles the vulnerability to developing substance abuse. Thus, patients with ADHD develop substance abuse disorder more frequently than the general population⁽⁶⁾ and at a younger age⁽⁷⁾. Adolescents with ADHD have an earlier onset of substance abuse and a chronic progression, compared to those without ADHD. Also, this category of patients have a shorter period between the first consumption and the development of a substance abuse disorder, higher functional impairment, and a greater severity of the disorder⁽⁸⁾ . Treatment for this diagnostic association also presents significant challenges, as this population tends to progress more rapidly from episodic abuse to a substance use disorder, drop out the treatment more quickly, and have a higher rate of psychiatric comorbidities than patients with SUD without ADHD⁽⁹⁾.

Impulsivity, decreased sensitivity to rewards, inhibition deficit and top-down control in ADHD represent risk factors for the development of a substance abuse pathology, explained by dysfunctions in mesolimbic and mesocortical dopaminergic pathways⁽¹⁰⁾. Reward deficits in ADHD are clinically supported by difficulties in postponing rewards and delayed gratification, preferring to lower rewards earlier than higher later.

Numerous studies demonstrate decreased quality of life in patients with SUD-comorbid ADHD compared to the general population. Factors influencing quality includ the severity of substance abuse, the type of substances used, and the onset age⁽¹¹⁾. A systematic review analyzed the quality of life, through the WHOQOL questionnaire, based on a demographic diversity of substance abuse. The results showed the impairment of quality of life in various areas, the most affected being the somatic and the psychological ones⁽¹²⁾. Pharmacological studies show that the quality of life in ADHD comorbid with SUD is improved with specific psychotropic treatment⁽¹³⁾.

Methodology

The methods applied in the present study continue previous published research on a group of 104 adult patients diagnosed with SUD who were evaluated in order to identify suggestive symptoms for ADHD⁽¹⁴⁾. The subjects were selected from an inpatient addiction unit, from the “Prof. Dr. Alexandru Obregia” Clinical Hospital of Psychiatry from Bucharest. The patients, aged between 18 and 28 years old, were divided into two groups:

the control group – patients with addictions and no ADHD symptoms (60 subjects)

the study group – patients with addictions and ADHD symptoms (44 subjects).

The present research is a cross-sectional, nonexperimental, observational study and evaluates the well-being of the subjects through their subjective perception of reality, in relation to their own goals and values. The quality of life of the subjects was evaluated using a questionnaire designed by the authors of this research, adapted from the model recommended by the World Health Organization (WHO). The questionnaire consists of 26 questions regarding the individual’s perception of their own quality of life, health, energy levels, physical appearance, financial status, performance and sleep quality. Each question offers five answer options, ranging from a minimum level (not at all/very unsatisfactory/never) to a maximum level (extremely/very satisfied/always), from which the subjects were asked to choose only one option.

Results

Table 1 presents the questions included in the quality-of-life questionnaire, along with the median for each question and the corresponding response option. For questions related to the general assessment of quality of life, satisfaction with one’s health, enjoyment of life, sleep quality, relaxing activities, perception of financial status, job satisfaction, intimate life, personal performance, and support from peers, the median was represented by response option 3: “Neither low, nor high/Moderately”.
 

Figure 1 shows a graphical representation of the total score obtained in the selected sample for the quality-of-life questionnaire, within the range of 53 to 122, and the mean of 88.51 ± 15.17. The range was 69.
 

The following analysis explores a potential correlation between the score obtained on the quality-of-life questionnaire and the presence or absence of diagnostic criteria for ADHD. Subjects diagnosed with ADHD had a quality-of-life score ranging from 53 to 122, with a mean ± SD of 88.07 ± 15.79 and a median of 89. Subjects who did not meet the diagnostic criteria for ADHD had a total score ranging from 55 to 117, with a mean ± SD of 89 ± 14.58 and a median of 90. An Independent Samples t-Test showed that there was no statistically significant difference between the mean scores based on the presence or absence of an ADHD diagnosis (t=0.31, p=0.76). Therefore, in the selected sample, the association of substance use with ADHD-specific manifestations did not influence the answers or the total score for the quality-of-life questionnaire.

Figure 2 provides a comparative view of the total quality of life scores in the groups with and without ADHD. The similarity in scores between the two groups is evident, with relatively equal mean values (89 ± 14.58 for the group without ADHD and 88.07 ± 15.79 for the group with ADHD). The range of variation was 69 (minimum: 53; maximum: 122) for the group with ADHD and 62 for the group without ADHD (minimum: 55; maximum: 117).
 

For Factor 1, the grouped questions primarily relate to the perception of one’s own health and physical appearance (health, energy level, relaxing activities, physical appearance, presence of negative feelings). Factor 4 appears to group questions related to the material aspects and the infrastructure that determine the quality of life, referring to financial status, access to health services, and living conditions. Factor 5 groups questions related to the level of self-confidence (e.g., “How secure do you feel?”, “How much do you enjoy life?”, “How easily do you manage daily activities?”, “How satisfied are you with your intimate life?”). Factor 7 pertains to the two questions related to illness and treatment and their impact on the individual’s quality of life.

Conclusions

Most of the subjects answered that they enjoyed life moderately, that they feeled moderately insecure in daily activities and financial resources, and considered that they had difficulties in completing routine tasks.

In the selected sample, the association of substance use with ADHD-specific manifestations did not influence the answers or the total score for the quality-of-life questionnaire. It should be noted that, in the present study, the group consisted of individuals who used psychoactive substances, and future research would benefit from expanding the study by including a sample from the general population and subsequently comparing quality-of-life scores.

Many researchers investigating this topic have determined negative correlations between quality-of- life measures and severity or comorbidities of adult ADHD⁽¹⁵⁾. So far, most of the research has focused on the dynamic evaluation of quality of life before and after certain therapeutic interventions for ADHD and SUD symptoms⁽¹⁶⁾.

For this research, it is important to note that a conclusive factor analysis requires a minimum of 200 responses, while the selected sample consisted of only 104 subjects.

Therefore, expanding the research to include at least 200 subjects is necessary to test whether the factorial results remain consistent with these numbers. This would allow for potential adaptation, development, and subsequent validation of the quality-of-life questionnaire.

The results of our study replicate other cross-sectional research demonstrating that there are no differences between patients with SUD and ADHD and those without ADHD in terms of quality of life⁽¹⁷⁾. An explanation for the fact that an association between the level of quality of life and the presence of ADHD symptoms could not be determined can be discussed from the exaggerated self-perception of these individuals. The enhanced self-evaluation on some items of quality of life on adult ADHD patients with SUD can be explained by their specific positive appraisal.  

Autori pentru corespondenţă: Alexandra Buică E-mail: alexandra.buica@umfcd.ro

CONFLICT OF INTEREST: none declared.

FINANCIAL SUPPORT: none declared.

This work is permanently accessible online free of charge and published under the CC-BY.