ADHD in the UK

I don't want to keep you too long today but thought it worthwhile to bring the paper by Adrian Hire and colleagues [1] to your attention and the suggestion that "socioeconomic deprivation" may play a role when it comes to ADHD (attention-deficit hyperactivity disorder).

Based on data derived from the "Clinical Practice Research Datalink (CPRD)" - a UK based resource "providing anonymised primary care records for public health research since 1987" - researchers set about looking at those children/young adults diagnosed with ADHD between 2004 and 2013. This information was stratified according to the region where the general practice (GP) surgery was based added to which a measure of deprivation status was calculated ("Practice Index of Multiple Deprivation (IMD) score").

The results: well, aside from something of quite a stable incidence (that's incidence not prevalence) of ADHD apart from the last 2 years studied (interestingly), Hire et al also reported that: "In almost every year studied, incidence rates were highest among the most deprived patients and lowest among the least deprived patients." They concluded that there may be quite a bit more to see when it comes to socioeconomic deprivation (i.e. poverty etc.) and the label ADHD.

Obviously one has to be a little guarded in making too many sweeping generalisations from this data (including the use of "a surrogate measure" for deprivation status) but there is quite a bit more work to do in this area. Other statistics for example, have come to similar conclusions about socioeconomic disparities and ADHD diagnosis [2] crossing different geographies as well. That and the suggestion that ADHD + other diagnoses might show important effects as a function of societal variables such as poverty (see here) and one has some intriguing hypotheses to test with some potentially important conclusions reflective of lots of variables including social policy.

Music: Coldplay - Adventure Of A Lifetime (and a great video).

----------

[1] Hire AJ. et al. ADHD in the United Kingdom: Regional and Socioeconomic Variations in Incidence Rates Amongst Children and Adolescents (2004-2013). J Atten Disord. 2015 Nov 23. pii: 1087054715613441.

[2] QuickStats: Percentage of Children Aged 5-17 Years with Diagnosed Attention Deficit/Hyperactivity Disorder (ADHD),by Poverty Status and Sex - National Health Interview Survey, 2011-2014. MMWR Morb Mortal Wkly Rep. 2015 Oct 16;64(40):1156.

----------

Hire AJ, Ashcroft DM, Springate DA, & Steinke DT (2015). ADHD in the United Kingdom: Regional and Socioeconomic Variations in Incidence Rates Amongst Children and Adolescents (2004-2013). Journal of attention disorders PMID: 26604267

Mental illness and blood-borne viral infections

"People with serious mental illness are at risk of blood-borne viral infections." But: "Serious mental illness is unlikely to be a sole risk factor and risk of blood-borne viral infection is probably multifactorial."

Those were the primary conclusions reached in the paper by Elizabeth Hughes and colleagues [1] (open-access) who conducted a systematic review and meta-analysis of the available peer-reviewed literature looking at the prevalence of various blood-borne viral infections in people diagnosed with a serious mental illness. The infections included in their analysis were: “hepatitis C”, ‘HCV’, “hepatitis B”, ‘HBV’, “HIV”, “human immunodeficiency virus” alongside the more generic term“blood borne virus”. These terms were cross-referenced with various search criteria covering that 'serious mental illness' term including schizophrenia, bipolar disorder and more generic descriptions such as mental disorder/illness.

From nearly 400 research abstracts, 91 studies were analysed. Forty-four studies including over 21,000 research participants assessed HIV infection. Nineteen studies with over 8000 participants looked at the prevalence of HBV. Twenty-eight studies (n=14,888) looked at HCV.

The results: "The prevalences of blood-borne viral infections in people with serious mental illness were higher than in the general population in places with low prevalence of blood-borne viruses, such as the USA and Europe, and on par with the general population in regions with high prevalence of blood-borne viruses (Africa for HIV and southeast Asia for hepatitis B virus and hepatitis C virus)." The actual estimates came in at 6% of those with a serious mental illness in the USA with HIV (compared with ~2% in Europe) and and an estimated 17% with HCV in the USA (compared with ~5% in Europe). Data for other continents of the world were a little more hit-and-miss according to the available studies for analyses.

Whilst important data, such findings need to be treated carefully save any sweeping generalisations made about such associations. If there are lessons that need to be learned when it comes to the concept of mental ill-health, it is that (a) stigma and 'generalisation' can cause infinite problems to this community (and indeed, influence their seeking help in the first place) and (b) health inequalities are already rife when it comes to the application of psychiatric labels (see here for example). Society is getting better at talking about blood-borne viral infections such as HIV these days (made easier by certain high-profile people talking about their own experiences) and in that context, the data from Hughes et al appears in more enlightened times.

As to the implications from this data, the authors make a number of important points outside the need for further "robust epidemiological research" in this area. Discussions about sexual health should be more widely encouraged with people with a serious mental illness is one aspect (yes, people with schizophrenia and/or bipolar disorder still can and do have sex) as is the need to focus on other possible routes of infection such as intravenous drug use. Again, avoiding any sweeping generalisations, Hughes and colleagues also talk about how "patients might have sexual partners who inject drugs, facilitating viral transmission" and the need to cover this topic during consultations particularly if relationships include "sexual exploitation and violence." Allied to the topic of appropriate management as and when blood-borne viral infections are detected [2], and one can perhaps see some wide-ranging conversations needed to be had in this important area.

I might also suggest that a heightened risk of other blood-borne infections potentially associated with certain psychiatric labels might also be included in those conversations and the possibility of where that could lead [3]...

Music: Izzy Bizu - White Tiger.

----------

[1] Hughes E. et al. Prevalence of HIV, hepatitis B, and hepatitis C in people with severe mental illness: a systematic review and meta-analysis. Lancet Psychiatry. 2015. Nov 24.

[2] Helleberg M. et al. Associations between HIV and schizophrenia and their effect on HIV treatment outcomes: a nationwide population-based cohort study in Denmark. Lancet HIV. 2015 Aug;2(8):e344-50.

[3] Okusaga O. et al. Combined Toxoplasma gondii seropositivity and high blood kynurenine - Linked with nonfatal suicidal self-directed violence in patients with schizophrenia. J Psychiatr Res. 2015 Oct 9;72:74-81.

----------

Hughes, E., Bassi, S., Gilbody, S., Bland, M., & Martin, F. (2015). Prevalence of HIV, hepatitis B, and hepatitis C in people with severe mental illness: a systematic review and meta-analysis The Lancet Psychiatry DOI: 10.1016/S2215-0366(15)00357-0

Cochrane does methylphenidate for ADHD

'Cochrane does' in the title of this post refers to the Cochrane Library and the sterling work that is done by the Cochrane Reviews to analyse the collected peer-reviewed evidence on various aspects of health and wellbeing and provide a sort of 'state of the evidence' address. It's something that has graced this blog before (see here).

This time around attention has turned to the paper by Ole Jakob Storebø and colleagues [1] (open-access) who started with the objective to: "assess the beneficial and harmful effects of methylphenidate for children and adolescents with ADHD [attention-deficit hyperactivity disorder]." Methylphenidate, more readily known by the brand names Concerta or Ritalin is one of the management tools of choice for some people diagnosed with ADHD as part of a suite of stimulant medicines indicated for the condition. As what can happen with quite a few medicines in the medicinal chest, methylphenidate is also becoming a nootropic of choice in these days of so-called cognitive enhancers or smart drugs and particularly with reference to the academic rat race that many people find themselves in.

The paper from Storebø et al surveyed the peer-reviewed research literature on the topic of methylphenidate (MPH) and ADHD up to February of this year (2015) identifying some 185 trials: "randomised controlled trials (RCTs) comparing methylphenidate versus placebo or no intervention in children and adolescents aged 18 years and younger with a diagnosis of ADHD." They concluded that there was some evidence that MPH was a useful medicine for improving things like teacher-rated ADHD scores and parent-reported quality of life among children and young adults with ADHD. Serious, life-threatening side-effects were also fairly rare based on the data inspected. Good news indeed.

But... as per some other write-up of the study findings (see here), the picture was not universally rosy when it came to MPH use and ADHD in the research literature. So: "The most common non-serious adverse events were sleep problems and decreased appetite. Children in the methylphenidate group were at 60% greater risk for trouble sleeping/sleep problems..., and 266% greater risk for decreased appetite... than children in the control group." Such findings even within the context of requiring better designed trials to assess MPH, are slightly worrying and are perhaps the reasons why the BBC headline on this study read: "Experts call for caution over Ritalin." Other recent research has also come to similar conclusions [2].

Bearing in mind my oft-cited caveats on this blog about not giving anything that looks, sounds or smells like clinical advice, I have a few things to add to the Storebø report based on my reading of some of the research literature in this area. First and foremost is the fact that outside of something like MPH (and a few other medicines) science and medicine have not got a great deal of other therapeutic options to offer when ADHD is diagnosed. Yes, behavioural interventions can be implemented; indeed, even something like sleep interventions have been discussed with ADHD in mind (see here). But surprisingly little else is available unless one considers that some of the more 'complementary' interventions might also be useful for some (see here).

Second, as per quite a bit of professional opinion these days, childhood developmental disorders such as ADHD really need to be tackled in the younger years in view of the 'risks' attached to their perpetuation into adulthood. Take for example the emerging research suggesting that ADHD might 'prime' for something like psychosis or schizophrenia in later years (see here) (albeit with other important variables potentially playing a role) and one has a taste of what future enhanced risks might be associated with the label. Even some of the authors from the current Cochrane review have some previous research form in this area [3]. This also covers other more societal risks too (see here).

Finally is the idea that whilst no-one particularly likes the idea that children and young adults are being dispensed quite powerful medicines, things like MPH with appropriate medicines management, can make a real difference to people's lives. With my autism research blogging hat on and acknowledging how autism and ADHD show some significant 'overlapping' (see here) the peer-reviewed research confirms such 'positive effects' [4] at least for some. And yes, we need to know more about who the potential best and non-responders are likely to be.

Further research is of course indicated in this area including that related to the mechanism of effect from something like MPH (see here). As part of a suite of intervention options for labels like ADHD (including something as simple as promoting physical activity), MPH continues to have a place subject to the idea that the use of such medication should be treated as a time-limited experiment with an N=1 and appropriate monitoring for side-effects.

Music: Where's Your Car Debbie - Slaves.

----------

[1] Storebø OJ. et al. Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD). Cochrane Database of Systematic Reviews. 2015; Issue 11. Art. No.: CD009885.

[2] Kidwell KM. et al. Stimulant Medications and Sleep for Youth With ADHD: A Meta-analysis. Pediatrics. 2015 Nov 23. pii: peds.2015-1708.

[3] Storebø OJ. & Simonsen E. The Association Between ADHD and Antisocial Personality Disorder (ASPD): A Review. J Atten Disord. 2013 Nov 27.

[4] Posey DJ. et al. Positive effects of methylphenidate on inattention and hyperactivity in pervasive developmental disorders: an analysis of secondary measures. Biol Psychiatry. 2007 Feb 15;61(4):538-44.

----------


Storebø OJ, Ramstad E, Krogh HB, Nilausen TD, Skoog M, Holmskov M, Rosendal S, Groth C, Magnusson FL, Moreira-Maia CR, Gillies D, Buch Rasmussen K, Gauci D, Zwi M, Kirubakaran R, Forsbøl B, Simonsen E, & Gluud C (2015). Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD). The Cochrane database of systematic reviews, 11 PMID: 26599576

Theory of mind and major depressive disorder

Today I'm briefly serving up the paper by Emre Bora & Michael Berk [1] for your daily reading and the results of their meta-analysis stating that: "Theory of mind abilities are impaired during depression."

Based on data derived from 18 studies covering over 600 participants diagnosed with major depressive disorder (MDD) and over 500 asymptomatic controls, the Bora/Berk paper suggests that there may be much more to see when it comes to the psychological processes of attributing mental states and the myriad of presentations covered under the banner of depression.

Whilst I am interested in the label of depression on this blog (see here and see here for example) my reasoning for discussing this specific paper is slightly broader; namely in the context of how theory of mind (ToM) has waxed and waned specifically with autism in mind (see here). If one considers that depression shows more than a passing connection to quite a lot of autism (see here) or indeed, some of the somatic comorbidity talked about with autism in mind (see here), one might see a way whereby some of the historical scientific discussions about ToM and autism may have neglected the role of some quite important comorbidity. I say all this in the context that the label of autism rarely appears in some sort of diagnostic vacuum (see here) as per discussions on [its] ESSENCE (see here).

One other area of interest that I'd like to bring to your attention that might 'unite' some of the findings regarding ToM and autism and depression, is the idea that biological processes may play an important role in any relationship. Take for example the interesting data coming out in the peer-reviewed domain suggesting that inflammation or inflammatory process may affect important psychological processes such as social cognition as per the findings from Moieni and colleagues [2] (see here for my take). Inflammation and [some] autism y'say? Inflammation and [some] depression? Well, let's just to say that I don't think anyone is in a position to rule anything out at the moment (see here and see here respectively).

Music: Grace - You Don't Own Me.

----------

[1] Bora E. & Berk M. Theory of mind in Major Depressive Disorder: A meta-analysis. Journal of Affective Disorders. 2015. Nov 23.

[2] Moieni M. et al. Inflammation impairs social cognitive processing: A randomized controlled trial of endotoxin. Brain, Behavior, and Immunity. 2015. May 10.

----------

Bora, E., & Berk, M. (2015). Theory of mind in Major Depressive Disorder: A meta-analysis Journal of Affective Disorders DOI: 10.1016/j.jad.2015.11.023

Scurvy and autism continued

"Scurvy as a Manifestation of Food Selectivity in Children with Autism" read the title of the paper by Nina Ma and colleagues [1] continuing a topic of some interest to this blog regarding the need for more research and practical focus on nutritional insufficiency and deficiency when it comes to the label of autism (see here for example).

As per other occasions when scurvy - a condition linked to a deficiency of vitamin C - has been talked about in the context of autism (see here), the Ma paper continues an all-too familiar theme of how "a long-standing history of food selectivity" when it comes to at least some autism, can have some pretty serious onward health implications (see here). Alongside reporting on how "an elaborate panel of tests and procedures were undertaken before the diagnosis of scurvy was made" in seven children, all of whom had a developmental disorder, Ma et al highlight how vitamin C treatment "led to rapid recovery of symptoms." Without doing a Linus Pauling special on the wonders of vitamin C (accepting that in some respects he might not have been too far off the mark) I would draw your attention to some very preliminary work looking at vitamin C supplementation (sorry, ascorbic acid) with autism in mind [2].

That none of the children included in the Ma study "were supplemented with a multivitamin" at the time of their clinical evaluation is also relevant, especially in light of some rather sweeping generalisations made about other autism research on the use of dietary/nutritional supplementation and autism (see here). Certainly, what this and other related research suggests is that (a) a diagnosis of autism may indeed place someone at risk of certain dietary or nutritional issues and (b) appropriate screening should be in place to mitigate any potential health effects from such dietary-related problems. Oh, and just in case you were wondering, the horror that is a gluten- and casein-free (GFCF) diet when done correctly, is probably not to blame for cases of scurvy in relation to autism (see here)...

Music: Nothing But Thieves - Trip Switch.

----------

[1] Ma NS. et al. Brief Report: Scurvy as a Manifestation of Food Selectivity in Children with Autism. J Autism Dev Disord. 2015 Nov 21.

[2] Dolske MC. et al. A preliminary trial of ascorbic acid as supplemental therapy for autism. Prog Neuropsychopharmacol Biol Psychiatry. 1993 Sep;17(5):765-74.

----------

Ma NS, Thompson C, & Weston S (2015). Brief Report: Scurvy as a Manifestation of Food Selectivity in Children with Autism. Journal of autism and developmental disorders PMID: 26590972

Camel milk and autism: two humps or three?

In a previous post with the cringe-worthy title: 'Camel milk for autism: one hump or two?' (you can see why I could never be a comedian) I talked about some rather intriguing research [1] asking whether, under double-blind, placebo-controlled conditions, camel milk could affect various clinical measures of severity when it comes to the label of autism, some autism. The answer was very possibly, yes; with the strong requirement for quite a bit more follow-up research in this area.

Lo and behold, yet more data has emerged from the research pen of one Laila Al-Ayadhi and colleagues [2] (open-access available here) on the topic of camel milk and autism and specifically the idea that: "camel milk could be [a] very promising therapeutic intervention in ASD [autism spectrum disorder]." Again, under double-blind, placebo-controlled conditions, Al-Ayadhi et al describe how 2 weeks of camel milk (raw or boiled) seemed to show some 'significant differences' on schedules such as the CARS (Childhood Autism Rating Scale), SRS (Social Responsiveness Scale) and the ATEC (Autism Treatment Evaluation Checklist). The placebo (cow milk) group by contrast, didn't show anything at all in terms of significant changes between baseline and post-intervention testing occasions.  The ATEC in particular, is something I'm quite keen to see more autism investigations using (see here).

I have some time for Dr/Prof. Al-Ayadhi and colleagues given some previous musings on their wide and varied research with autism in mind (see here). This recent work continues one of their important themes based on the idea that not all mammalian milk forms are alike (see here) and hence, following a tradition potentially implicating milk and dairy products in some autism (see here), a switch to other varieties of milk outside of those normally populating our diet might be beneficial for at least some. Other more 'N=1' reports [3] have offered similar discussions on this topic.

As per my previous musings on this topic, I can't readily offer a substantial and/or universal reason for what it is about camel milk that may be important to some people on the autism spectrum. Lactose content, milk protein structure or nutritional content are perhaps some of the most pertinent variables to consider given that all have some research 'history' when it comes to at least some autism (see here for some discussion on the seemingly forgotten work by Tim Buie et al on lactose issues and autism for example). In other peer-reviewed publications, Dr/Prof. Al-Ayadhi has talked about the antioxidant properties of camel milk as being key [4]. I'm hoping that in future times I might be able to discuss further this area of investigation as and when some research ideas in my own day job reach fruition.

And just in case you think I'm advocating camel milk for all autism, no I'm not. As we've seen from other research outside of autism recently, personalised nutrition is the way forward [5] not sweeping generalisations...

Music to close and a song that's growing on me (I think I need some earworm therapy).
----------

[1] Al-Ayadhi LY. et al. Behavioral Benefits of Camel Milk in Subjects with Autism Spectrum Disorder. J Coll Physicians Surg Pak. 2015 Nov;25(11):819-823.

[2] Bashir S. & Al-Ayadhi LY. Effect of camel milk on thymus and activation-regulated chemokine in autistic children: double-blind study. Pediatr Res. 2014 Apr;75(4):559-63.

[3] Adams CM. Patient report: autism spectrum disorder treated with camel milk. Glob Adv Health Med. 2013 Nov;2(6):78-80.

[4] Al-Ayadhi LY. & Elamin NE. Camel Milk as a Potential Therapy as an Antioxidant in Autism Spectrum Disorder (ASD). Evid Based Complement Alternat Med. 2013;2013:602834.

[5] Zeevi D. et al. Personalized Nutrition by Prediction of Glycemic Responses. Cell. 2015 Nov 19;163(5):1079-1094.

----------

Al-Ayadhi LY, Halepoto DM, Al-Dress AM, Mitwali Y, & Zainah R (2015). Behavioral Benefits of Camel Milk in Subjects with Autism Spectrum Disorder. Journal of the College of Physicians and Surgeons--Pakistan : JCPSP, 25 (11), 819-823 PMID: 26577969