الفهرس 
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Abstract
There has been an agreement on the high rate of co-occurrence of substance use disorders and other psychiatric disorders since long period. Relation between ADHD and substance abuse goes back to early 1970s when prevalence of ADHD among substance abuse patients was first studied.
Different models to explain relation between ADHD and substance use have been proposed. ADHD may be considered as a risk factor for SUD. Common genetic background for both ADHD and SUD plays a also a contributing factor. Other authors propose a more complicated causal relation between ADHD and SUD having conduct disorder ”CD” and then antisocial personality disorder ”ASD” as mediating factors in this relation.
Many authors report that patients with both ADHD and substance abuse have an earlier onset of substance use problems, a longer course, and greater severity, with more relapses and greater difficulty remaining abstinent.
The aim of the present work was:
- To estimate the prevalence rate of adult attention-deficit hyperactivity disorder among substance use inpatients in El-Maamoura psychiatric hospital.
- To compare substance use inpatients with and without adult attention-deficit hyperactivity disorder regarding the onset, the severity and the type of substance use.
The study was conducted on 102 inpatients consecutively admitted in addiction centre of El Maamoura psychiatric hospital during a period of six months starting on 1st of January 2011 till 30th of June 2011.
All patients aged 18-60 years with single or multiple substance dependence at the earliest after a 14-day detoxification therapy who accepted to participate and signed a written consent were included in the study. Patients with other psychiatric illnesses that may interfere with judgment (psychosis, mania, delirium) were excluded.
Arabic version of Wender Utah Rating Scale (WURS) (Appendix I) was used for retrospective assessment of symptoms of childhood ADHD. Arabic version of Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist (Appendix II) was used to screen for symptoms of adult ADHD. Psychiatric interview was done using DSM- VI- TR criteria to reach to final diagnosis.
The collected data were analysed using Chi-square test (X2), Monte carlo test (MCp), Fisher Exact test (FEp), Mann Whitney test (Z).
Results of this study revealed that:
- All patients were males due to the limited resources of the addiction center at El-Maamoura psychiatric hospital having only male wards.
- The age of the patients ranged from 19 to 53 years old with a mean of 31.16 ± 5.96 years.
- As regard the marital status, 52 were single (51.0%), 8 were engaged (7.8%), 26 were married (25.5%) and 16 were divorced (15.7%).
- Regarding the residence, 20 patients came from rural areas (19.6%), while 82 patients came from urban areas (80.4%).
- Among the sample, 4 weren’t working (3.9%), 24 patients were manual workers (23.5%), 24 were semi-skilful (23.5%), 20 were skilful (19.6%) and 30 patient had professional or clerical occupations (29.4%).
- Among the sample, 6 patients were illiterate (5.9%), 10 could only read and write (9.8%), 14 were educated till preparatory school (13.7%), 42 till secondary school (41.2%) and 30 were graduated from university (29.4%).
- Seventy two patients had no past history of prior psychiatric illness other than ADHD (70.6%), whereas 30 patients had past history of psychiatric illness (29.4%) of which 28 patients had past history Axis I diagnoses in the form of major depressive disorder (MDD) (27.5%) and 12 patients had Axis II diagnoses as antisocial personality disorder (11.8%), 4 were diagnosed as borderline personality disorder(3.9%).
- Sixty six patients had no past medical history (64.7%), whereas 14 patients had past history of seizures (13.7%), 10 had past history of hepatitis C virus (HCV) (9.8%) and 4 had past history of hepatitis B virus (HBV) (3.9%).
- Regarding the type of substance of abuse, we found that 60 patients were abusing alcohol (58.8%), the whole 102 patients were abusing cannabis (100%), 50 patients were abusing benzodiazipines (49.0%), the whole 102 patients were abusing opioids of which 38 were abusing heroin alone (37.3%), 22 were abusing tramadol alone (21.6%), 42 were abusing both (41.1%), 4 patients were abusing cocaine (3.9%) and 46 were abusing other substances of abuse which they described as pills and medications (45.1%).
- Regarding the number of substances of abuse and substance abuse onset, we found that number of substances ranged from 3 to 7 substances with a mean of 4.54 ± 0.95 substances and substances abuse onset ranged from 8 to 31 years old with a mean of 14.75 ± 3.63 years old.
- The numbers of hospital admissions ranged from 1 to 30 times with a mean of 4.61 ± 5.93 times and longest period of abstinence ranged from 14 to 1200 days with a mean of 179.72±254.18 days.
- Twenty six patients had history of legal problems either in the form of temporary arrest, attendance to court or imprisoning (25.5%) while 76 had no history of legal problems (74.5%).
- Injections were the preferred route of administration of heroin for 70 patients (68.6%), 42 patients used the burn route (41.2%) and 18 used the sniffing route (17.6%).
- According to results of Arabic version of Wender Utah Rating Scale (WURS), 64 patients had positive history of childhood ADHD (63.7%) while 38 patients screened negative (37.3%). Following application of Arabic version of Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist, 44 patients had positive results for adult ADHD symptoms (43.1%) while 58 screened negative (56.9%).
- Thirty six patients were diagnosed as having adult ADHD (35.3%) while 66 did not have adult ADHD (64.7%) according to DSM-IV text revised criteria.
- Among the adult ADHD patients, 16 patients met the criteria for adult ADHD, predominantly inattentive type (ADHD-I) (15.7%), 2 patients met the criteria for adult ADHD, predominantly hyperactive-impulsive type (ADHD-H) (2.0%) and 18 patients met the criteria for adult ADHD, combined type (ADHD-C) (17.6%).
- There was no statistical difference between the ADHD and non ADHD groups regarding the demographic data except for the occupation. Following Post comparison analysis, it was found that occupations associated with most significant difference between the two groups were manual works (FEp = 0.031) and semi-skilful jobs (p = 0.007).
- Regarding past history of psychiatric illness in general, 20 patients of the non ADHD group had past history of psychiatric illness (30.3%), while 10 patients of the ADHD group gave positive past history of psychiatric illness (27.8%). There was no statistical difference on comparison = 0.072, p = 0.789).
- Twelve patients of the non ADHD group gave history of personality disorder following psychiatric interviewing (18.2%) of which 8 patients fulfilled criteria for antisocial personality disorder and 4 patients had borderline personality disorder, whereas 4 patients of the ADHD group had personality disorders (11.1%) being all related to antisocial personality disorder. There was no statistical difference (MCp = 0.484).
- Past history of major depressive disorder (MDD) was found in 18 patients of the non ADHD group (37.2%), while 10 patients of the ADHD group gave positive history for major depressive disorder (MDD) (27.8%). There was no statistical difference = 0.003, p = 0.956).
- Regarding past history of hepatitis C virus (HCV), 2 patients of the non ADHD group had positive history (3.0%), while 8 patients of the ADHD group had positive history of HCV infection (22.2%) and the difference was statistically significant (FEp = 0.003).
- As regard past history of hepatitis B virus (HBV), none of the non ADHD patients had such history, while 4 patients of the ADHD group gave positive history for HBV infection (11.1%) and the difference was statistically significant (FEp = 0.014).
- Comparison between the two studied groups according to types of substance of abuse showed that 36 patients of the non ADHD group were abusing alcohol (54.5%), while the ADHD group showed a higher rate of alcohol abuse having 24 patients on alcohol (66.7%) but the difference was not significant ( = 1.413, p = 0.235). Benzodiazipenes were among substances of abuse for 28 patients of the non ADHD group (42.4%), while 22 patients of the ADHD group were abusing it (61.1%) with no statistical difference ( = 3.255, p = 0.071). Four patients of the ADHD group were abusing cocaine (11.1%) while non of the non ADHD group and there was statistical significant difference (FEp = 0.014). Both cannabis and opioids were being abused by all patients in the sample. Other substances of abuse as pills and medications were being abused by 34 patients of the non ADHD group were abusing it (51.5%), while 12 patients of the ADHD group gave such history (33.3%) and there was no statistical difference ( = 3.110, p = 0.078).
- Number of substances of abuse, for the non ADHD group number of substances ranged from 3 to 6 substances with a mean of 4.47 ± 0.98 substances, while for the ADHD patients number of substances ranged from 4 to 7 substances with a mean of 4.67 ± 0.89 substances and there was no statistical difference (p = 0.565).
- As regard onset of substance abuse, in the non ADHD patients the onset ranged from 10 to 31 years old with a mean of 15.58 ± 3.84, while in the ADHD patient group onset was about 2 years earlier ranging from 8 to 18 years old with a mean of 13.22 ± 2.63 and the difference was statistically significant (p = 0.001).
- Regarding number of hospital admissions, in the non ADHD group numbers ranged between 1 and 20 times with a mean of 3.39 ± 3.95 times, while in the ADHD group number of admissions ranged between 1 and 30 with a mean of 6.83 ± 8.05 times and the difference was statistical significant (p = 0.049).
- In view of longest period of abstinence, in the non ADHD group the period ranged between 14 and 1200 days with a mean of 209.82±282.0 days, while in the ADHD group the period was shorter ranging from 14 to 700 days with a mean of 124.53±171.86 days and the difference was statistical significant (MWp = 0.045).
- Twelve patients of the non ADHD group had history of legal problems (18.2%), while 14 patients of the ADHD group who gave such history (38.9%) and the difference was statistical significant ( = 5.259, p = 0.022).
- In the non ADHD group 42 patients used injection as a mode of administration (63.6%), while 28 patients of the ADHD group used to inject heroin (77.8%) and there was no significant difference ( = 2.164, p = 0.141). Regarding burning, it was the preferred route for 26 patients of the non ADHD group (39.4%), while 16 patients of the ADHD group used this route (44.4%) with no significant difference ( = 0.245, p = 0.620). Sniffing was the preferred route for 4 patients of the non ADHD group (6.1%), whereas 14 patients of the ADHD group used to sniff heroin (38.9%) and the difference was statistical significant (FEp = <0.001).
- A multivariate regression model was done to assess significant variables of substance abuse in relation to presence or absence of adult ADHD. The two most significant variables were number of hospital admissions with an odds ratio of 1.125 and sniffing as a preferred route of administration of heroin with an odds ratio of 2.614.
- Further comparison between different subtypes of adult ADHD was done. Regarding number of hospital admissions, for the non ADHD group number of hospital admissions ranged from 1 to 20 times with a mean of 3.39 ± 3.95, while for the inattentive ADHD patients number of hospital admissions ranged from 1 to 20 admissions with a mean of 5.63 ± 5.89 and difference was statistically significant (p = 0.019), for the combined ADHD patients number of admissions ranged from 1 to 30 admissions with a mean of 4.67 ± 0.97 and there was no statistical difference (p = 0.184) and for the hyperactive-impulsive ADHD patients number of admissions ranged from 12 to 12 times with a mean of 12.00 ± 0.00 and there was no statistical difference (p = 0.114).
- Mean age of onset of substance abuse was earliest among the hyperactive-impulsive ADHD patients ranging from 12 to 12 years with a mean of 12.00 ± 0.00 but there was no statistical difference (p = 0.067), in the non ADHD patients the onset ranged from 10 to 31 years old with a mean of 15.58 ± 3.84, while for the inattentive ADHD patients onset of substance abuse ranged from 10 to 17 years with a mean of 14.38 ± 2.36 and difference was statistically significant (p = 0.025), for the combined ADHD patients onset of substance abuse ranged from 8 to 18 years with a mean of 13.22 ± 3.02 and difference was statistically significant (p = 0.014).
- The 2 patients of the hyperactive-impulsive ADHD group had the highest rate for legal problems (100.0%) with statistical significant difference (FEp = 0.040), whereas 12 patients of the non ADHD group had history of legal problems (18.2%), while 4 patients of the inattentive ADHD group who gave such history (25.0%) and there was no statistical difference (FEp = 0.503), for the combned ADHD group 8 patients gave history of legal problems (44.4%) with statistical significant difference ( = 5.3778, p = 0.020).
- Highest rates for sniffing as a preferred route of administration of heroin were observed among the 8 patients of the combined ADHD group (44.4%) and the difference was statistical significant (FEp = <0.001), whereas sniffing was the preferred route for 4 patients of the non ADHD group (6.1%), whereas 6 patients of the inattentive ADHD group used to sniff heroin (37.5%) with statistical significant difference (FEp = 0.003), neither of the 2 patients of the hyperactive-impulsive ADHD group gave such history and there was no significant difference (FEp = 1.000).
- There was no statistical significant difference between other routes of administration of heroin among different subtypes of adult ADHD.
- Sixty four patients of the total studied sample had past history of childhood ADHD following application of Arabic version of Wender Utah Rating Scale (WURS). Only 36 patients of this group fulfilled the DSM – IV TR criteria for adult ADHD.
- Further comparison between those with childhood only ADHD and patients with adult ADHD showed that as regard onset of substance abuse, in the childhood ADHD patients the onset ranged from 11 to 23 years old with a mean of 14.86 ± 2.85, while in the ADHD patient group onset was earlier ranging from 8 to 18 years old with a mean of 13.22 ± 2.63 and the difference was statistically significant (p = 0.036).
- Regarding number of hospital admissions, in the childhood ADHD patients numbers ranged between 1 and 20 times with a mean of 4.21 ± 4.86 times, while in the ADHD group number of admissions ranged between 1 and 30 with a mean of 6.83 ± 8.05 times but the difference was not statistical significant (p = 0.393).
- In view of longest period of abstinence, in the childhood ADHD patients the period ranged between 14 and 1200 days with a mean of 271.50±363.85 days, while in the adult ADHD group the period was shorter ranging from 14 to 700 days with a mean of 124.53±171.86 days and the difference was statistical significant (p = 0.027).
- Four patients of the childhood ADHD patients had history of legal problems (14.3%), while 14 patients of the ADHD group who gave such history (38.9%) and the difference was statistical significant (p = 0.030).