ADHD in Adult Psychiatric Outpatients

To the Editor: Anxiety and depression are two of the most common complaints of psychiatric outpatients, and anxiety and mood disorders are among the most common psychiatric disorders in the United States (1). These disorders are also frequently associated with attention-deficit hyperactivity disorder (ADHD) in both children and adults (2).

ADHD is a chronic psychiatric disorder characterized by early childhood onset of motor overactivity (hyperactivity), distractibility (inattentiveness), and impulsivity that often persists into adulthood (3). ADHD affects 3 to 5 percent of all classroom children, and clinically significant signs and symptoms of ADHD may persist into adulthood in 60 to 70 percent of the cases. Therefore, one would expect to find a disproportionately large number of psychiatric patients with ADHD.

This report describes a study that attempted to measure the frequency of ADHD in a cross-sectional sample of 212 randomly assigned adult psychiatric outpatients, none of whom were referred for or were being treated for ADHD. The sample consisted of 130 veterans being treated in a Veterans Affairs mental hygiene clinic, 42 outpatients at a community mental health center, and 40 consecutive private psychiatric outpatients first seen by the first author in 1993 and followed for 24 to 36 months.

Of the 212 outpatients, only 114, or 54 percent, received a complete ADHD assessment. Ninety-eight patients (46 percent) were excluded because of psychosis or evidence of structural brain damage. The average age of the 114 patients was 43 years, 68 percent were male, and 97 percent were Caucasian. Sixty-one percent were married, and 21 percent were divorced. Fifty-one percent were employed; the remainder were partly or total disabled or retired.

Formal ADHD evaluation consisted of a review of family and childhood history and a review of grade-school report cards and school records whenever possible. Patients were also evaluated by DSM-III-R criteria for ADHD. They were scored on the Wender Utah Rating Scale (WURS) and Wender's suggested 25 items (WURS-25), which measure recollected early grade school problems (4), and on Hallowell and Ratey's 20-item Suggested Adult ADHD Criteria (5). The first author interviewed significant others and first-degree relatives using Wender's ten-item Parental Rating Scale (WPRS), which measures observations of motor overactivity, distractibility, and impulsivity, or relied on professional staff's observations.

To receive a diagnosis of ADHD, a subject had to meet eight or more of the DSM-III-R criteria and have a score of 46 or more on the WURS-25, 12 or more on the Hallowell-Ratey criteria, or 10 or more on the WPRS. The subject also had to be found positive for ADHD by clinical observation, by observation of a significant other, or according to childhood school records.

Fifty-seven of the 114 patients, or 50 percent, received a diagnosis of ADHD. Patients who were diagnosed with ADHD met a mean±SD of 10.3±2.5 DSM-III-R criteria. WPRS scores were obtained for 40 patients; the mean score was 15.9±3.8. The mean score on the Hallowell-Ratey scale was 17.2±1.6; on the WURS-25 it was 58.9±14.1; and on the WURS it was 113.8±28.3. Childhood school records indicated ADHD in 27 of 30 cases in which records were available.

Seventeen cases of panic disorder were found in the ADHD group, but only four cases in the group without ADHD. A total of 29 cases of anxiety disorder were found in the ADHD group, compared with 11 in the other group.

Fifteen of the 18 outpatients, or 83 percent, who were assessed from the community mental health center received a diagnosis of ADHD. This disproportionately high figure might be related to a higher incidence of poverty among these patients, but further study is needed.

This preliminary study of ADHD in adults relied primarily on clinical observations over comparatively long time periods, ranging from 24 to 36 months. Future studies will require separating the processes of diagnosis, ADHD assessment, and treatment into controlled segments for the sake of believability and accuracy. However, the fact that the patients in the study were observed over a substantial period increases the likelihood that they did in fact have ADHD.