ADHD medication cuts hard outcomes most in people who have already had them

When an adult with a fresh ADHD diagnosis asks whether to start medication, the conversation usually turns on concentration, work and side effects. A Karolinska Institutet team led by Le Zhang used Swedish registers to look at a different set of outcomes: suicide attempts, substance misuse, injuries, road accidents and convictions.

Two years after diagnosis

The design emulates a target trial. People who started ADHD medication within three months of diagnosis were compared with those who did not, weighted for psychiatric and physical diagnoses, other psychotropic drugs and earlier use of care. Ages ran from 6 to 64, median 17.4 years, and 41.3% were female. Initiation was associated with fewer first episodes of suicidal behaviour (14.5 v 16.9 per 1000 person years), substance misuse (58.7 v 69.1), transport accidents (24.0 v 27.5) and criminality, counted as any conviction (65.1 v 76.1). Accidental injuries stayed almost level at 88.5 v 90.1.

Split by prior events

At baseline, 8.7% of the cohort already had suicidal behaviour on record, 20.8% substance misuse and 37.3% a conviction. Among people without a previous event, only suicidal behaviours and transport accidents fell significantly. Among people with one, all five outcomes fell, and the gap between the two groups reached significance for substance misuse (P<0.01) and criminality (P=0.02).

The patients who make prescribers hesitate

My reading is that the strongest case for medication sits with the patients clinicians approach most cautiously. A past overdose, a drink-driving conviction or a suicide attempt often makes a psychiatrist slow down before a stimulant, and makes a psychologist put off the referral. In this cohort, those were the people whose rates dropped furthest. With a newly diagnosed adult who carries such a history, I would raise the medication question early in the plan, next to the safety plan and the work on substance use.