Reviewed by Hannah Mullens (1,2) and Susan Young (3,2)
1 Department of Psychology, University of Bath, UK
2 Broadmoor Hospital, West London Mental Health Trust, London, UK
3 Centre for Mental Health, Division of Brain Sciences, Department of Medicine, Imperial College, London
An abundance of research investigating the co-occurrence of ADHD and substance use disorder (SUD) has been reported recently. As mentioned by Dora Wynchank in the recent news review, substance abuse is highly comorbid with ADHD. A complex relationship between ADHD and substance misuse exists, with ADHD being over-represented in substance use populations (1), and substance misuse being more prevalent within ADHD populations (40-50%) in comparison to the general population (15-30%) (2). Theories exist and have been investigated in an attempt to explain this link, including recent research into the shared genetic underpinnings of both disorders (3).
This paper by Nehlin, Nyberg and Öster researched the link between ADHD and SUD directly, interviewing those with ADHD and SUD to obtain their perspectives on the role of drugs and alcohol in their lives. It is an important study because for the first time we hear the patients’ voice on this topic.
14 adult participants were recruited for this study, consisting of 8 females and 6 males with a mean age of 29.6 ± 7.8 years. Participants were recruited from a pool of individuals with on-going outpatient contact with the Department of Psychiatry, Uppsala University Hospital, Sweden. Of the 14 recruited, 12 had an ADHD diagnosis, one had an ADD diagnosis and one reported severe ADHD symptoms which were under investigation. All participants reported problematic on-going or former drug or alcohol use.
A semi-structured interview with open ended questions was conducted with each participant, lasting for 25 to 40 minutes with the option of a break in the middle of the interview. Interviews were conducted with the use of an interview guide and questions prompting the participant to reflect on their perceptions and experiences of substance use. A deductive content analysis method was used to analyse areas of interest as determined by theory and the authors’ clinical expertise.
All participants described positive effects of alcohol/drugs. Frequently participants reported enjoying the calm and pause they provided from restlessness and agitation. Alcohol and drugs were also perceived to improve their social interactions, removing unwanted distractions and sensations and allowing them to focus. Participants were able to reflect on the negative effects of alcohol/drugs, mentioning general negative outcomes (e.g. unemployment and debt) but also reporting how alcohol/drugs lowered their impulse control further and increased their aggression, compounding their ADHD symptoms.
As a result of the positive effects of drugs and alcohol, participants expressed how they could then accomplish activities in daily life in a better way, for example reading a book, cleaning, and taking care of family. Participants indicated how this subsequently allowed them to feel “normal” and accepted by those around them and to have a sense of belonging. This feeling of normality and acceptance was a recurring theme that the participants said they sought from substances.
Participants were asked which situations put them most at risk and triggered their drug and alcohol intake and, whilst very few specific situations were given, impulsivity was generally regarded as a risk factor/trigger. In addition those with co-occurring mood disorders attributed depressive thoughts to be a risk factor.
In relation to treatment and prevention, many of the participants indicated a belief that an earlier diagnosis of their ADHD would have prevented the development of substance dependence due to the understanding and help accompanying the diagnosis. Some regarded ADHD medication to be of great help, enabling them to deal with their substance use problems as the medication now achieved the same benefits that the drug/alcohol used to achieve. Participants highlighted the need for psychiatric staff and caregivers to discuss the motives underlying alcohol and drug use in order to understand the person and situation and inform their treatment, rather than the current exclusion of those with SUD from ADHD treatment.
This research highlights the importance of investigating the motivating factors underlying behaviours, specifically substance use. It could be argued that those motivated to use drugs/alcohol as a method of achieving normality and a sense of belonging in their life would benefit strongly from ADHD medication. However they are in a ‘catch 22’ as typically they are excluded from treatment due to their substance misuse.
This is a review of the article “Nehlin, C., Nyberg, F., & Öster, C. The patient’s perspective on the link between ADHD and substance use: A qualitative interview study. Journal of Attention Disorders. 2015; 19(4): 343-350.”
1. van Emmerick-van Oortmerssen, K., van de Glind, G., van den Brink, W., Smit, F., Crunelle, C., Swets, M., & Schoevers, R. Prevalence of attention-deficit hyperactivity disorder in substance abuse disorder patients: A meta-analysis and meta-regression analysis. Drug and Alcohol Dependence. 2012; 122(1-2): 11-19.
2. Kalbag, A.S., & Levin, F. R. Adult ADHD and Substance Abuse: Diagnostic and Treatment Issues. Substance Use and Misuse. 2005; 40(13-14): 1955-1981.
3. Skoglund, C., Chen, Q., Franck, J., Lichtenstein, P., & Larsson, H. Attention-deficit/hyperactivity disorder and risk for substance use disorders in relatives. Biological Psychiatry. 2015; 77(10): 880-886.