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Healthcare utilization and comorbidity shortly before suicide mortality in patients with attention-deficit/hyperactivity disorder: a nested case–control study

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Abstract

Background

Few studies have analyzed healthcare utilization before suicide among individuals with attention-deficit/hyperactivity disorder (ADHD). This study examined the pattern of healthcare utilization and comorbidities shortly before death among patients with ADHD who died by suicide and compared these data with those of living controls. This study used Taiwan’s National Health Insurance Research Database to identify patients with ADHD (N = 379,440) between January 1, 2001, and December 31, 2016. Subsequently, the researchers identified 159 suicide decedents by linking each patient with the National Mortality Database. By conducting a nested case–control study with risk-set sampling from the ADHD cohort, the researchers selected 20 age- and sex-matched controls (n = 3180) for each patient who died by suicide (cases). The researchers then applied conditional logistic regression to investigate differences in healthcare utilization as well as psychiatric and physical comorbidities between case patients and controls. Case patients had higher healthcare utilization within 3 months before suicide, particularly in the psychiatry, emergency, internal medicine, neurosurgery, and plastic surgery departments. These patients also had higher risks of psychiatric comorbidities, including schizophrenia, bipolar disorder, depressive disorder, and sleep disorder, as well as physical comorbidities such as hypertension and other forms of heart disease. Among patients with ADHD, suicide decedents had increased healthcare utilization and higher risks of specific psychiatric and physical comorbidities than living controls. Thus, for suicide prevention among individuals with ADHD, suicide risk must be detected early and comorbidities should be adequately managed.

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References

  1. Faraone SV, Asherson P, Banaschewski T, Biederman J, Buitelaar JK, Ramos-Quiroga JA, Rohde LA, Sonuga-Barke EJ, Tannock R, Franke B (2015) Attention-deficit/hyperactivity disorder. Nat Rev Dis Primers 1:15020

    Article  PubMed  Google Scholar 

  2. Volkow ND, Swanson JM (2013) Clinical practice: adult attention deficit-hyperactivity disorder. N Engl J Med 369:1935–1944

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. Lin YJ, Yang LK, Gau SS (2016) Psychiatric comorbidities of adults with early- and late-onset attention-deficit/hyperactivity disorder. Aust N Z J Psychiatry 50:548–556

    Article  PubMed  Google Scholar 

  4. de Zeeuw EL, van Beijsterveldt CEM, Ehli EA, de Geus EJC, Boomsma DI (2017) Attention deficit hyperactivity disorder symptoms and low educational achievement: evidence supporting a causal hypothesis. Behav Genet 47:278–289

    Article  PubMed  PubMed Central  Google Scholar 

  5. Sun S, Kuja-Halkola R, Faraone SV, D’Onofrio BM, Dalsgaard S, Chang Z, Larsson H (2019) Association of psychiatric comorbidity with the risk of premature death among children and adults with attention-deficit/hyperactivity disorder. JAMA Psychiatry 76:1141–1149

    Article  PubMed  PubMed Central  Google Scholar 

  6. Chen VC, Chan HL, Wu SI, Lee M, Lu ML, Liang HY, Dewey ME, Stewart R, Lee CT (2019) Attention-deficit/hyperactivity disorder and mortality risk in Taiwan. JAMA Netw Open 2:e198714

    Article  PubMed  PubMed Central  Google Scholar 

  7. World Health Organization ( 2019) Suicide in the world: global health estimates. World Health Organization, Geneva, Switzerland

  8. Ljung T, Chen Q, Lichtenstein P, Larsson H (2014) Common etiological factors of attention-deficit/hyperactivity disorder and suicidal behavior: a population-based study in Sweden. JAMA Psychiatry 71:958–964

    Article  PubMed  Google Scholar 

  9. Septier M, Stordeur C, Zhang J, Delorme R, Cortese S (2019) Association between suicidal spectrum behaviors and attention-deficit/hyperactivity disorder: a systematic review and meta-analysis. Neurosci Biobehav Rev 103:109–118

    Article  PubMed  Google Scholar 

  10. Smalley SL, McGough JJ, Moilanen IK, Loo SK, Taanila A, Ebeling H, Hurtig T, Kaakinen M, Humphrey LA, McCracken JT, Varilo T, Yang MH, Nelson SF, Peltonen L, Jarvelin MR (2007) Prevalence and psychiatric comorbidity of attention-deficit/hyperactivity disorder in an adolescent Finnish population. J Am Acad Child Adolesc Psychiatry 46:1575–1583

    Article  PubMed  Google Scholar 

  11. Fitzgerald C, Dalsgaard S, Nordentoft M, Erlangsen A (2019) Suicidal behaviour among persons with attention-deficit hyperactivity disorder. Br J Psychiatry. https://doi.org/10.1192/bjp.2019.128

    Article  PubMed  Google Scholar 

  12. Chang Z, D’Onofrio BM, Quinn PD, Lichtenstein P, Larsson H (2016) Medication for attention-deficit/hyperactivity disorder and risk for depression: a nationwide longitudinal cohort study. Biol Psychiatry 80:916–922

    Article  PubMed  PubMed Central  Google Scholar 

  13. Quinn PD, Chang Z, Hur K, Gibbons RD, Lahey BB, Rickert ME, Sjolander A, Lichtenstein P, Larsson H, D’Onofrio BM (2017) ADHD medication and substance-related problems. Am J Psychiatry 174:877–885

    Article  PubMed  PubMed Central  Google Scholar 

  14. Instanes JT, Klungsoyr K, Halmoy A, Fasmer OB, Haavik J (2018) Adult ADHD and comorbid somatic disease: a systematic literature review. J Atten Disord 22:203–228

    Article  PubMed  Google Scholar 

  15. Stene-Larsen K, Reneflot A (2019) Contact with primary and mental health care prior to suicide: a systematic review of the literature from 2000 to 2017. Scand J Public Health 47:9–17

    Article  PubMed  Google Scholar 

  16. Hunt IM, Kapur N, Robinson J, Shaw J, Flynn S, Bailey H, Meehan J, Bickley H, Burns J, Appleby L, Parsons R (2006) Suicide within 12 months of mental health service contact in different age and diagnostic groups: national clinical survey. Br J Psychiatry 188:135–142

    Article  PubMed  Google Scholar 

  17. Laugesen B, Mohr-Jensen C, Boldsen SK, Jorgensen R, Sorensen EE, Gronkjaer M, Rasmussen P, Lauritsen MB (2018) Attention deficit hyperactivity disorder in childhood: healthcare use in a Danish birth cohort during the first 12 years of life. J Pediatr 197:233–240

    Article  PubMed  Google Scholar 

  18. Ernster VL (1994) Nested case-control studies. Prev Med 23:587–590

    Article  CAS  PubMed  Google Scholar 

  19. Ury HK (1975) Efficiency of case-control studies with multiple controls per case: continuous or dichotomous data. Biometrics 31:643–649

    Article  CAS  PubMed  Google Scholar 

  20. Essebag V, Platt RW, Abrahamowicz M, Pilote L (2005) Comparison of nested case-control and survival analysis methodologies for analysis of time-dependent exposure. BMC Med Res Methodol 5:5

    Article  PubMed  PubMed Central  Google Scholar 

  21. Liu CY, Hung YT, Chuang YL, Chen YJ, Weng WS, Liu JS, Liang KY (2006) Incorporating development stratification of Taiwan townships into sampling design of large scale health interview survey. J Health Manag 4:1–22

    CAS  Google Scholar 

  22. Charlson ME, Pompei P, Ales KL, MacKenzie CR (1987) A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 40:373–383

    Article  CAS  PubMed  Google Scholar 

  23. Laanani M, Imbaud C, Tuppin P, Poulalhon C, Jollant F, Coste J, Rey G (2020) Contacts with health services during the year prior to suicide death and prevalent conditions a nationwide study. J Affect Disord 274:174–182

    Article  PubMed  Google Scholar 

  24. Fontanella CA, Warner LA, Hiance-Steelesmith DL, Sweeney HA, Bridge JA, McKeon R, Campo JV (2017) Service use in the month and year prior to suicide among adults enrolled in Ohio Medicaid. Psychiatr Serv 68:674–680

    Article  PubMed  Google Scholar 

  25. Taurines R, Schmitt J, Renner T, Conner AC, Warnke A, Romanos M (2010) Developmental comorbidity in attention-deficit/hyperactivity disorder. Atten Defic Hyperact Disord 2:267–289

    Article  PubMed  Google Scholar 

  26. Zalsman G, Hawton K, Wasserman D, van Heeringen K, Arensman E, Sarchiapone M, Carli V, Hoschl C, Barzilay R, Balazs J, Purebl G, Kahn JP, Saiz PA, Lipsicas CB, Bobes J, Cozman D, Hegerl U, Zohar J (2016) Suicide prevention strategies revisited: 10-year systematic review. Lancet Psychiatry 3:646–659

    Article  PubMed  Google Scholar 

  27. O’Neill S, Graham B, Ennis E (2019) Emergency department and hospital care prior to suicide: a population based case control study. J Affect Disord 249:366–370

    Article  CAS  PubMed  Google Scholar 

  28. Miller IW, Camargo CA Jr, Arias SA, Sullivan AF, Allen MH, Goldstein AB, Manton AP, Espinola JA, Jones R, Hasegawa K, Boudreaux ED, Investigators E-S (2017) Suicide prevention in an emergency department population: the ED-SAFE study. JAMA Psychiatry 74:563–570

    Article  PubMed  PubMed Central  Google Scholar 

  29. Saunders KE, Hawton K, Fortune S, Farrell S (2012) Attitudes and knowledge of clinical staff regarding people who self-harm: a systematic review. J Affect Disord 139:205–216

    Article  PubMed  Google Scholar 

  30. Taylor TL, Hawton K, Fortune S, Kapur N (2009) Attitudes towards clinical services among people who self-harm: systematic review. Br J Psychiatry 194:104–110

    Article  PubMed  Google Scholar 

  31. Brunkhorst-Kanaan N, Libutzki B, Reif A, Larsson H, McNeill RV, Kittel-Schneider S (2021) ADHD and accidents over the life span—a systematic review. Neurosci Biobehav Rev 125:582–591

    Article  PubMed  Google Scholar 

  32. Hurtig T, Taanila A, Moilanen I, Nordstrom T, Ebeling H (2012) Suicidal and self-harm behaviour associated with adolescent attention deficit hyperactivity disorder-a study in the Northern Finland Birth Cohort 1986. Nord J Psychiatry 66:320–328

    Article  PubMed  Google Scholar 

  33. Arsenault-Lapierre G, Kim C, Turecki G (2004) Psychiatric diagnoses in 3275 suicides: a meta-analysis. BMC Psychiatry 4:37

    Article  PubMed  PubMed Central  Google Scholar 

  34. Levy T, Kronenberg S, Crosbie J, Schachar RJ (2020) Attention-deficit/hyperactivity disorder (ADHD) symptoms and suicidality in children: the mediating role of depression, irritability and anxiety symptoms. J Affect Disord 265:200–206

    Article  PubMed  Google Scholar 

  35. Tistarelli N, Fagnani C, Troianiello M, Stazi MA, Adriani W (2020) The nature and nurture of ADHD and its comorbidities: a narrative review on twin studies. Neurosci Biobehav Rev 109:63–77

    Article  PubMed  Google Scholar 

  36. Lugo-Candelas C, Corbeil T, Wall M, Posner J, Bird H, Canino G, Fisher PW, Suglia SF, Duarte CS (2020) ADHD and risk for subsequent adverse childhood experiences: understanding the cycle of adversity. J Child Psychol Psychiatry. https://doi.org/10.1111/jcpp.13352

    Article  PubMed  PubMed Central  Google Scholar 

  37. Hoza B (2007) Peer functioning in children with ADHD. Ambul Pediatr 7:101–106

    Article  PubMed  PubMed Central  Google Scholar 

  38. Daley D, Birchwood J (2010) ADHD and academic performance: why does ADHD impact on academic performance and what can be done to support ADHD children in the classroom? Child Care Health Dev 36:455–464

    Article  CAS  PubMed  Google Scholar 

  39. Johnston C, Mash EJ (2001) Families of children with attention-deficit/hyperactivity disorder: review and recommendations for future research. Clin Child Fam Psychol Rev 4:183–207

    Article  CAS  PubMed  Google Scholar 

  40. Connor DF, Edwards G, Fletcher KE, Baird J, Barkley RA, Steingard RJ (2003) Correlates of comorbid psychopathology in children with ADHD. J Am Acad Child Adolesc Psychiatry 42:193–200

    Article  PubMed  Google Scholar 

  41. Biederman J, Ball SW, Monuteaux MC, Mick E, Spencer TJ, Mc CM, Cote M, Faraone SV (2008) New insights into the comorbidity between ADHD and major depression in adolescent and young adult females. J Am Acad Child Adolesc Psychiatry 47:426–434

    Article  PubMed  Google Scholar 

  42. Chen Q, Sjolander A, Runeson B, D’Onofrio BM, Lichtenstein P, Larsson H (2014) Drug treatment for attention-deficit/hyperactivity disorder and suicidal behaviour: register based study. BMJ 348:g3769

    Article  PubMed  PubMed Central  Google Scholar 

  43. Juurlink DN, Herrmann N, Szalai JP, Kopp A, Redelmeier DA (2004) Medical illness and the risk of suicide in the elderly. Arch Intern Med 164:1179–1184

    Article  PubMed  Google Scholar 

  44. Wynchank D, Bijlenga D, Lamers F, Kooij JJS, Bron TI, Beekman ATF, Penninx B (2018) The association between metabolic syndrome, obesity-related outcomes, and ADHD in adults with comorbid affective disorders. J Atten Disord 22:460–471

    Article  PubMed  Google Scholar 

  45. Hennissen L, Bakker MJ, Banaschewski T, Carucci S, Coghill D, Danckaerts M, Dittmann RW, Hollis C, Kovshoff H, McCarthy S, Nagy P, Sonuga-Barke E, Wong IC, Zuddas A, Rosenthal E, Buitelaar JK, Consortium A (2017) Cardiovascular effects of stimulant and non-stimulant medication for children and adolescents with ADHD: a systematic review and meta-analysis of trials of methylphenidate, amphetamines and atomoxetine. CNS Drugs 31:199–215

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  46. Hawkins M, Schaffer A, Reis C, Sinyor M, Herrmann N, Lanctot KL (2016) Suicide in males and females with cardiovascular disease and comorbid depression. J Affect Disord 197:88–93

    Article  PubMed  Google Scholar 

  47. Arrondo G, Solmi M, Dragioti E, Eudave L, Ruiz-Goikoetxea M, Ciaurriz-Larraz AM, Magallon S, Carvalho AF, Cipriani A, Fusar-Poli P, Larsson H, Correll CU, Cortese S (2022) Associations between mental and physical conditions in children and adolescents: an umbrella review. Neurosci Biobehav Rev 137:104662

    Article  PubMed  Google Scholar 

  48. Andersson M, Hedman L, Bjerg A, Forsberg B, Lundback B, Ronmark E (2013) Remission and persistence of asthma followed from 7 to 19 years of age. Pediatrics 132:e435-442

    Article  PubMed  Google Scholar 

  49. Hawton K, Zahl D, Weatherall R (2003) Suicide following deliberate self-harm: long-term follow-up of patients who presented to a general hospital. Br J Psychiatry 182:537–542

    Article  PubMed  Google Scholar 

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Acknowledgements

This manuscript was edited by Wallace Academic Editing.

Funding

This research was supported by grants from the Ministry of Science and Technology, Taiwan (MOST 108-2314-B-532-005 and 110-2314-B-532-003-MY3) and Taipei City Hospital (10801-62-004, 10901-62-009, 11001-62-006 and 11101-62-014). The funding sources had no involvement in the study design, data collection, analysis, interpretation of data, writing of the report, or the decision to submit the paper for publication.

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W-CL and C-JK conceived and designed the study. C-JK acquired the data. S-SS performed the statistical analysis. S-YT and C-CC provided administrative and material support. W-CL and C-JK drafted the manuscript. C-HP made critical revisions to the manuscript for critical intellectual content, and S-YT and C-CC supervised the study.

Corresponding author

Correspondence to Chian-Jue Kuo.

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The authors declare no competing interests.

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Lee, WC., Pan, CH., Su, SS. et al. Healthcare utilization and comorbidity shortly before suicide mortality in patients with attention-deficit/hyperactivity disorder: a nested case–control study. Eur Child Adolesc Psychiatry 32, 2009–2019 (2023). https://doi.org/10.1007/s00787-022-02038-y

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  • DOI: https://doi.org/10.1007/s00787-022-02038-y

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