Is there a relationship between adult ADHD and bipolar symptoms? A cross-sectional study with primary care applicants in Ankara, Turkey
Irem Ekmekci Erteka, Mustafa Ilhanb, Asiye Ugras Dikmenb, Melih Gozukarab
a Gazi University, Faculty of Medicine, Department of Psychiatry, Ankara; b Gazi University, Faculty of Medicine, Department of Public Health, Ankara, Turkey
Background: Attention Deficit Hyperactivity Disorder (ADHD) and Bipolar Affective Disorder (BAD) are two diseases that are frequently interrelated and there are difficulties in diagnosis and treatment. In this study, it was aimed to examine the prevalence of adult ADHD and its relationship with BAD.
Methods: 1517 people attending primary health care services in Ankara were evaluated with sociodemographic data, Adult Attention Deficit and Hyperactivity Disorder Self-Report (ASRS), and Bipolar Prodrome Symptom Scale (BPSS).
Results: The prevalence of adult ADHD was 3.7%. The rate of the participants whose bipolar frequency score was above the cut-off point was 47.2% in the non-ADHD group and 70.4% in the ADHD group. These rates were 7.6% and 37.0% according to the bipolar severity scores, respectively. 14.5% of the ADHD group and 1.6% of the non-ADHD group had a forensic event (p <0.001). 18.2 of the ADHD group and 9.0% of the non-ADHD group had a traffic accident (p=0.041).
Conclusion: A significant relationship between ADHD and prodromal BAD symptoms was found in people over 18 years of age who applied to primary health care institutions, and ADHD was associated with an increased risk of forensic events and traffic accidents.
Keywords: Attention Deficit Hyperactivity Disorder; Bipolar Affective Disorder; prevalence; comorbidity
Attention Deficit and Hyperactivity Disorder (ADHD) is an early onset neurodevelopmental disorder characterized by inattention, hyperactivity, and impulsivity (1). In longitudinal studies conducted with children and adolescents, it was found that there was an ongoing disorder in adolescence and adulthood in almost two-thirds of patients diagnosed in childhood (2). Reduced symptoms of hyperactivity with advancing age poses a challenge for disease recognition (3). Besides, many psychiatric comorbidities that frequently accompany ADHD have been the cause of misdiagnosis and inadequate treatment (4). In epidemiological studies conducted in different countries, it has been reported that the prevalence of ADHD in adults varies between 3-5% (5).
In Turkey, the prevalence of ADHD was reported as 8.1% in primary school children (6); and 2.6% in university students (7). However; the number of epidemiological studies on adult ADHD in the general population is limited. In a study conducted with 901 participants in Sivas, adult ADHD rate was found to be 3.8%, and a prevalence of 3.4% was reported from Denizli in an unpublished dissertation (8,9).
Bipolar Affective Disorder (BAD) is a common chronic disorder with significant chronic morbidity, and it is difficult to recognize in an early stage (10). In 20-30% of the patients, the first symptoms are seen before the age of 21 and in 10% of the patients, after 50 (11).
The presence of overlapping symptoms such as excessive talk, inattention, impulsivity, and increase in activities in BAD and ADHD; and their frequent comorbidity suggest a relationship between these two diseases (12,13). Some studies have reported high rates of ADHD in children with BAD, ranging from 57 to 100% (14). In our country, Ceylan et al. reported a 63% prevalence of ADHD in patients with pediatric bipolar disorder (15) In this early age period, it is hard to recognize the bipolar disorder, and differential diagnosis is a significant problem due to its overlapping symptoms with ADHD. In a follow-up study of children and adolescents with ADHD; comorbidity of bipolar disorder was found in 11% of the children, and an additional 12% increased risk was reported as a result of a four-year follow-up. In the same study, the rate of BAD was found to be 0% in the age and sex-matched healthy controls (16). In a large-sampled prospective study conducted with patients with BAD; the lifetime risk of ADHD comorbidity was found to be 9.5% (3).
The potential association between BAD and ADHD has been demonstrated in epidemiological, neuroimaging, and family studies, but this relationship is still unclear (17). In a study conducted with ADHD patients and their first-degree relatives, the ADHD rate was also found to be high in their relatives. Additionally, it was found that the risk of bipolarity increased 5-fold in the relatives of patients with ADHD and BAD comorbidity compared to the relatives of patients with ADHD only (18). These findings have contributed to the view that ADHD and bipolar disorder may be interrelated disorders and share common familial risk factors. Adult bipolar patients with ADHD have some differences in terms of symptomatology, phenomenological aspects, and disease course compared to patients without ADHD. In these patients, it was reported that the symptoms of BAD start earlier with more frequent episodes; the euthymic periods between episodes are shorter; alcohol-drug addiction, self-harm, and forensic events are more frequent (19,9,12,20). The chronic course of ADHD, its comorbidity with BAD, and the positive effect of treatment on the course of both diseases highlight the importance of screening ADHD in both adolescents and adults.
In this study, it was aimed to investigate the prevalence of adult ADHD and related sociodemographic variables in which there have been insufficient data in Turkey. Also, examining the relationship between adult ADHD and BAD was aimed. It was hypothesized that bipolar frequency and severity are going to be higher in participants with ADHD.
Materials and Methods
The study was carried out with the participants over 18 years old who applied to the primary health care services in various regions of Ankara. The universe of this research consists of the participants over the age of 18, who applied to 12 selected family health centers for any reason between 1 March and 8 March 2019. These 12 family health centers in four different socioeconomic regions were determined by the protocol of our university signed with the provincial health directorate for intern training. The number of people over the age of 18, who applied to these health institutions in the determined period was obtained one week before the study date. A total of 3215 people were admitted to these services. With an unknown frequency of 50%, 2% deviation, and 95% confidence interval, it was targeted to reach 1375 people. Consequently,1517 people were reached. The participants gave full informed consent to participate, and the ethical approval was obtained from the Gazi University Ethics Committee on date 26.07.2019 numbered 08.
This research was carried out by 57 interns in the Faculty of Medicine of Gazi University and the research assistants in the Department of Public Health. To ensure standardization, the intern physicians and research assistants were trained before the start of the study, who will work at the data collection stage for research, questionnaire, and application. The surveys were conducted between 1 March and 8 March 2019 by using face-to-face interviews and self-application methods.
Figure 1. Summarized information about participants.
Sociodemographic data form: This is the form containing the demographic information of the participants prepared by the researchers.
Adult Attention Deficit and Hyperactivity Disorder Self-Report Scale (ASRS): This scale was developed by the World Health Organization for screening ADHD symptoms in adults (21). The validity of the Turkish-language version was performed by Dogan et al (22). The 18 questions in the scale determine the frequency at which each symptom has appeared within the preceding six months. Nine items in this 5-point Likert-type scale concern lack of attention, and the other nine assess symptoms of hyperactivity/impulsiveness. In our study, for the overall reliability of ASRS, the Cronbach’s alpha value was .88.
Bipolar Prodrome Symptom Scale (BPSS): This is a self-report scale that provides a 14-point Likert-type assessment by scanning the mood symptoms separately in terms of severity and frequency. The validity and reliability study of the questionnaire was performed by Ömer Aydemir et al (23). The cut-off point for the frequency subscale was 17/18. The cut-off point for the severity subscale is calculated as 39/40. In our study, for the overall reliability of BPSS, the Cronbach’s alpha value was .94.
The data were evaluated by the SPSS 15.0 statistical package program. Descriptive statistics are presented as mean (±) standard deviation, median (min; max), frequency distribution, and percentage. Pearson Chi-square and Yates Correction Test were used and p values were presented two-tailed and Cronbach’s alpha coefficient was used as statistical methods. Cohen’s w formula used for calculating effect sizes. The statistical significance was accepted as p <0.05.
A total of 1517 people participated in the study. The mean age of the participants was 34.06 ± 12.58 (min: 16, max: 88).
The mean BPSS severity score was 19.86 ± 13.32, and the mean BPSS frequency score was 19.02 ± 12.93. The mean score of ASRS was 26.35 ± 10.84, and the two standard deviations above this (48) were taken as the cut-off point. In the 8.6% of the participants, the bipolar severity score was 40 points and above, and in the remaining 91.4%, it was 39 points or less. In 48% of the participants, the bipolar frequency score was found to be 18 and above, and in the remaining 52%, it was 17 or less. 96.3% of the participants had an ASRS score of 48 points or less. It was found that 3.7% of the patients had an ASRS score of 49 points and above (Table 1).
When the relationship between ADHD and BAD was examined; while the rate of bipolar frequency score above the cut-off point was 47.2% in non-ADHD patients; this rate was 70.4% in those with ADHD, and the results were statistically significant. When the ADHD and bipolar severity scores were examined, the results were 37.0% for those with ADHD and 7.6% for those without ADHD (Table 2).
No statistically significant difference was found between the patients with and without ADHD in terms of alcohol use, smoking and substance use, and self-harm. There was a significant difference in terms of psychiatric disease, forensic events, and traffic accidents. 23.6% of those with ADHD and 7.6% of those without ADHD had a psychiatric disease (p = 0.003). The rate of having a forensic event was 14.5% in the participants with ADHD and 1.6% in the ones without ADHD (p <0.001). 18.2% of those with ADHD and 9.0% of those without ADHD stated that they had a traffic accident (p = 0.041) (Table 3).
In this study, it was aimed to examine the prevalence of adult ADHD and its relationship with BAD in 1517 patients who applied to primary health care facilities in different regions of Ankara. In our study, the prevalence of adult ADHD was found as 3.7%. The rates of those reporting bipolar symptoms more frequently were 70.4% in those with ADHD and 47.2% in those without ADHD. These rates were 37.0% and 7.6% according to the bipolar severity scores. 14.5% of the ADHD group and 1.6% of the non-ADHD group had a forensic event, while 18.2 of the ADHD group and 9.0% of the non-ADHD group had a traffic accident.
In our country, there has been only one epidemiologic study determining the prevalence of ADHD. In this study; 901 participants in Sivas (a city in the central Anatolia Region of Turkey); were examined, the ratio of people above the ASRS cut-off point was 3.8%, which is similar to our study, and additionally, MINI Plus 5.0.0’s Adult Attention Deficit Hyperactivity module was used to test the diagnosis of ADHD. Eventually, the prevalence of ADHD was reported as 2.7% (8). Since our study was performed in a large-scale population for screening, it was not possible to conduct additional clinical interviews. It has been reported in the literature that the prevalence of ADHD is independent of economic development; the prevalence is 3.4% in developing countries, and 4.5% in the United Nations and it does not show much variation on a national scale (24,4,25). The samples of the studies conducted in this field in our country usually consist of psychiatric patients or some special populations. For example, while the prevalence of ADHD in university students was reported as 2.6% (7) on the other hand, it was found as 6.3% in medical school students (26). In two studies conducted with the patients who applied to the psychiatry outpatient clinic; the prevalence of ADHD was reported as 15.3% and 1.2% (27). It is suggested that such differences in these results are related to the heterogeneity of the sample group and the diagnostic tools that were used.
In a study conducted with the patients diagnosed with BAD; the rate of ADHD was reported as 15.9%. As a result, it was suggested that the probability of coexistence of two diseases is common, and therefore patients with BAD should be screened for ADHD (28). Another study stated that 21.7% of patients with BAD had ADHD comorbidity and this patient group had significantly more affective episodes compared to the ones diagnosed with only BAD (29). When the results of our study were examined in terms of the relationship between ADHD and BAD; while the rate of bipolar frequency score above the cut-off point was 47% in non-ADHD patients; this rate was found to be 70.4% in those with ADHD. Similarly, the rate of those who have a bipolar severity score above the cut-off point is 37.0% in the ADHD group and 7.6% in the non-ADHD group. The incidence of BAD and ADHD comorbidity in the adult population ranges from 5.1% to 47.1%. However, the majority of these studies were conducted with clinical populations (30). In a recent cohort study with 706 patients with BAD, the lifetime prevalence of ADHD was reported as 24.6%. In the same study, low levels of education and low socioeconomic level were seen in patients with BAD and ADHD comorbidity compared to patients with only BAD. It was stated that these distortions in academic and professional fields had started before the symptoms of BAD (20). In a non-clinical population, the incidence of ADHD and BAD comorbidity was reported as 0.8% among university students. In the same study, the history of parental abuse and the presence of severe depressive symptoms were stated as the predictors of this comorbidity (31).
In our study, no significant difference was found in terms of smoking, alcohol, and substance use between participants with and without ADHD. These results are not compatible with studies reporting an increase in alcohol and substance use rates among patients with ADHD (32,33,14). It is thought that this difference is caused by conducting this research in a non-clinical population, and the participants may have avoided giving information about alcohol and substance use.
According to the results of our study; forensic events and traffic accidents were significantly higher in patients with ADHD than in those without ADHD. In international studies conducted in many countries such as the USA, Canada, and Germany, two-thirds of young offenders; half of the adult prisoners were reported as diagnosed with childhood ADHD, and most of these people continued to have symptoms during adulthood (34). In a large sample-sized study conducted with 17408 patients with ADHD; the diagnosis of ADHD was reported to increase the risk of serious traffic accidents from 45% to 47%. It was emphasized that almost half of these accidents can be prevented by using medications for the treatment of ADHD (35).
In our study, no significant relationship was found between the diagnoses of ADHD and self-harm. Similarly, in a study conducted in Izmir in 2016, no significant difference was found between self-harm and ADHD (36). Since there have been several studies showing that there is a strong relationship between ADHD and self-harm in the literature (37), the contrary results of our study can be explained with the participants’ unwillingness about giving personal information of self-harm as well as alcohol or substance use.
In the literature, comorbidity of adult ADHD and BAD is associated with increased severity of the disease, poor prognosis, and alcohol-substance abuse, as well as other psychiatric disorders (3,19). Furthermore, medication treatment is a significant problem in these patients. The stimulants used in the treatment of ADHD may cause manic shifts or psychotic symptoms in patients with BAD, and they may also cause resistance to treatment (33). When all these factors are evaluated together; screening the comorbidity of ADHD and BAB in high-risk populations is considered to be a beneficial public health intervention in early diagnosis of the diseases, early initiation of treatment, or in the prevention of morbidity and mortality associated with this comorbidity.
In this study, since it was aimed to investigate the prevalence of adult ADHD in a large sample population and its relationship with BAD, screening scales for these two diseases were preferred. However, because of the large sample, it was not possible to perform a clinical interview with those who were thought to have a possible diagnosis of ADHD and BAD. Therefore, the diagnoses were not confirmed. Variables such as alcohol-substance use, forensic events, or self-harm may not reflect actual data due to memory factor or the fear of stigma as they were determined by the person’s declaration. Another limitation is, participants were recruited in primary health care services instead of interviewing through home visits so, it may not necessarily reflect community-based data. However, it is considered that selecting the participants from different socioeconomic regions of Ankara can give a general idea of the prevalence rates.
Despite all these limitations, in this cross-sectional study with a large sample of participants; it was found that there was a significant relationship between ADHD and prodromal BAD symptoms in people over 18 years of age who applied to primary health care institutions, and the ADHD was associated with an increased risk of forensic events and traffic accidents. To the best of our knowledge, this is the first population-based study examining the relationship of adult ADHD and BAD in Turkey, in which large-scale epidemiological studies on adult ADHD are limited.
Author statement contributors
IEE, MNI, and AUD were responsible for study design. MG, MNI, and AUD were responsible for recruiting the participants. MG made a statistical analysis. IEE prepared the manuscript and drafted the paper. MNI was responsible for the critical revision of the manuscript. All authors have contributed to and have approved the final manuscript.
Role of the funding source
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
We would like to show our great gratitude to all the interns of Gazi University Faculty of Medicine who have offered invaluable support. We would like to thank Prof. Filiz Karadağ and Dr. Meltem Çınar for their contribution to the study and to Prof. Ömer Aydemir for giving permission to use Bipolar Prodrome Symptom Scale and providing to us.
1. American Psychiatric Association., 2013. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. American Psychiatric Association, Arlington.
2. Simon V, Czobor P, Balint S, Meszaros A, Bitter I. Prevalence and correlates of adult attentiondeficit hyperactivity disorder: meta-analysis. Br J Psychiatry 2009; 194: 204–211.
3. Nierenberg AA, Miyahara S, Spencer T, Wisniewski SR, Otto MW, Simon N, et al. STEP-BD Investigators, Clinical and diagnostic implications of lifetime attention-deficit/hyperactivity disorder comorbidity in adults with bipolar disorder: data from the first 1000 STEP-BD participants. Biol. Psychiatry 2005;57: 1467–1473.
4. Kessler RC, Adler L, Barkley R, Biederman J, Conners CK, Demler, O, et al. The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. Am. J. Psychiatry 2006; 163: 716–723.
5. Wicks-Nelson R, Israel AC. Abnormal child and adolescent psychology. 8th ed., New York: Routledge; 2016. p. 227-228.
6. Ersan EE, Dogan O, Dogan S, Sumer H. The distribution of symptoms of attention-deficit/hyperactivity disorder and oppositional defiant disorder in school age children in Turkey. Eur Child Adolesc Psychiatry 2004; 13:354-361.
7. Dogan S, Oncu B, Varol-Saracoglu G, Kucukgoncu S. Prevalence of ADHD Symptoms in University Students and Developmental, Academic and Psychological Factors Related to Symptom Level. Turk Psikiyatri Derg 2008;10:109-115 (Turkish).
8. Yapicioglu B,Kavakci O,Guler AS,Semiz M,Dogan O. Adult ADHD prevalence in Sivas province and comorbid axis-I, axis-II diagnoses. Anadolu Psikiyatri Derg 2011;12: 177-184 (Turkish).
9. Simsek D. The prevalence of adult attention deficit hyperactivity disorder in Denizli city center. Postgraduate thesis. Pamukkale University Medical Faculty, Department of Psychiatry, Denizli, 2011 (Turkish).
10. Culver JL, Arnow BA, Ketter TA. Bipolar disorder: improving diagnosis and optimizing integrated care. J Clin Psychol 2007;63: 73-92.
11. Bebbington P, Ramana R. The Epidemiology of bipolar affective disorders. Soc Psychiatry Psychiatr. Epidemiol 1995; 30: 279-292.
12. Sachs GS, Baldassano CF, Truman CJ, Guille C. Comorbidity of attention deficit hyperactivity disorder with early-and late-onset bipolar disorder. Am J Psychiatry 2000;157: 466-468.
13. Geller B, Williams M, Zimerman B. Prepubertal and early adolescent bipolarity differentiate from ADHD by manic symptoms, grandiose delusions, ultra-rapid or ultradian cycling. J Affect Disord 1998;51: 81–91.
14. Kent L, Craddock N. Is there a relationship between attention deficit hyperactivity disorder and bipolar disorder? J Affect Disord 2003; 73: 211-221.
15. Ceylan MF, Akca OF, Yuce M, Bodur S. Comparison of symptoms of pediatric bipolar disorder in the manic phase and attention deficit and hyperactivity disorder. Klinik Psikofarmakoloji Bulteni- Bulletin of Clinical Psychopharmacology 2012;22:161-166.
16. Biederman J, Faraone S, Mick E, Wozniak J, Chen L, Ouellette C, at al. Attention-deficit hyperactivity disorder and juvenile mania: an overlooked comorbidity? J Am Acad Child Adolesc Psychiatry1996; 35:997-1008.
17. Klassen LJ, Katzman MA, Chokka P. Adult ADHD and its comorbidities, with a focus on bipolar disorder. J Affect Disord, 2010; 124(1-2): 1-8.
18. Faraone SV, Biederman J, Mennin D, Woznia J, Spencer T. Attention-deficit hyperactivity disorder with bipolar disorder: a familial subtype? J Am Acad Child Adolesc Psychiatry 1997; 36: 1378–1390.
19. Tamam L, Karakus G, Ozpoyraz N. Comorbidity of adult attentiondeficit hyperactivity disorder and bipolar disorder: prevalence and clinical correlates. Eur Arch Psychiatry Clin Neurosci 2006; 258: 385-393.
20. Pinna M, Visiol C, Rago CM, Manchia M, Tondo L, Baldessarini RJ. Attention deficit-hyperactivity disorder in adult bipolar disorder patients. J Affect Disord 2019; 243: 391-396.
21. Kessler RC, Adler L, Ames M, Delmer O, FaraoneS, Hiripi E, Walters EE. The World Health Organization Adult ADHD SelfReport Scale (ASRS): a short screening scale for use in the general population. Psychol Med 2005; 35:245-256.
22. Dogan S, Oncu B, Varol Saracoglu G, Kucukgoncu S.Validity and reliability of the Turkish version of the Adult ADHD Self-Report Scale (ASRS-v1. 1). Anadolu Psikiyatri Derg 2009; 10(2): 77-87.
23. Aydemir O, Oztekin S, Akdeniz F. Reliability and Validity Study of the Turkish Version of Bipolar Prodrome Symptom ScaleTurk Psikiyatri Derg- Turkish Jounal of Psychiatry 2018; 29(2):116-121 (Turkish).
24. Fayyad J, De Graaf R, Kessler R, Alonso J, Angermeyer M, Demyttenaere K, et al. Cross-national prevalence and correlates of adult attention-deficit hyperactivity disorder. Br J Psychiatry 2007; 190: 402–409.
25. Polanczyk G, De Lima MS, Horta BL, Biederman J, Rohde LA. Worldwide prevalence of ADHD: systematic review and metaregression analysis. Am J Psychiatry 2007;164: 942–948.
26. Taner E, Ilhan MN, Taner Y, Bekar EE, Senlik ZB. Tıp fakültesi altıncı sınıf öğrencilerinde DEHB yaygınlığı ve eğitim hayatı üzerine etkileri. Prevalence of Attention Deficit and Hyperactivity Disorder among students attending the sixth grade of medical school and the impact of the disorder on educational life. FU Saglık Bil Derg 2007;21:59-62 (Turkish).
27. Yalug I,Attention deficit hyperactivity disorder in adults: a review of Turkish data. Anadolu Psikiyatri Derg 2010;11:351-359 (Turkish).
28. Tamam L, Tuglu C, Karatas G, Ozcan S. Adult attention deficit hyperactivity disorder in patients with bipolar I disorder in remission: preliminary study. Psychiatry Clin Neurosci 2006; 60: 480-485.
29. Atesci F, Tuysuzogullari H,Ozdel O,Oguzhanoglu NK. Comorbidity of attention deficit hyperactivity disorder in adult bipolar I disorder: a preliminary study. Klinik Psikofarmakoloji Bulteni – Bulletin of Clinical Psychopharmacology 2010;20:66-73.
30. Wingo AP, Ghaemi SN. A systematic review of rates and diagnostic validity of comorbid adult attention-deficit/hyperactivity disorder and bipolar disorder. J Clin Psychiatry 2007;68:1776-1784.
31. Wang HR, Jung YE, Chung SK, Hong J, Kang NR, Kim MD, Bahk WM. Prevalence and correlates of bipolar spectrum disorder comorbid with ADHD features in nonclinical young adults. Journal of affect disord 2017; 207:175-180.
32. Etik C, Taner Y, Taner E, Arıkan Z, Alcohol addicted Attention deficit hyperactivity disorder in male patients. Bagimlilik Dergisi 2008; 9:14-17 (Turkish).
33. Perugi G, Ceraudo G, Vannucchi G, Rizzato S, Toni C, Dell’Osso L. Attention deficit/hyperactivity disorder symptoms in Italian bipolar adult patients: preliminary report. J Affect Disord 2013; 149: 430–434.
34. Young SJ, Adamou M, Bolea B, Gudjonsson G, Müller U, Pitts M, Asherson P. The identification and management of ADHD offenders within the criminal justice system: a consensus statement from the UK Adult ADHD Network and criminal justice agencies. BMC Psychiatry 2011; 11(1):32.
35. Chang Z, Lichtenstein P, D’onofrio BM, Sjölander A, Larsson H. Serious transport accidents in adults with attention-deficit/hyperactivity disorder and the effect of medication: a population-based study. JAMA Psychiatry 2014; 71(3): 319-325.
36. Belirgan S, Ersoy MA, Topcu Ersoy H. Prevalence of adult attention deficit hyperactivity disorder and comorbid axis-I disorders among first time applied cases of a general psychiatry outpatient clinic and a private psychotherapy centre. Psychiatry and Clinical Psychopharmacology 2018; 28(1): 25-35.
37. Furczyk K, Thome J. Adult ADHD and suicide. Atten Defic Hyperact Disord 2014; 6(3): 153-158.