Mortality in children, adolescents, and adults with attention deficit hyperactivity disorder: a nationwide cohort study.
BACKGROUND
Attention deficit hyperactivity disorder (ADHD) is a common mental disorder associated with factors that are likely to increase mortality, such as oppositional defiant disorder or conduct disorder, criminality, accidents, and substance misuse. However, whether ADHD itself is associated with increased mortality remains unknown. We aimed to assess ADHD-related mortality in a large cohort of Danish individuals.


METHODS
By use of the Danish national registers, we followed up 1·92 million individuals, including 32,061 with ADHD, from their first birthday through to 2013. We estimated mortality rate ratios (MRRs), adjusted for calendar year, age, sex, family history of psychiatric disorders, maternal and paternal age, and parental educational and employment status, by Poisson regression, to compare individuals with and without ADHD.


RESULTS
During follow-up (24·9 million person-years), 5580 cohort members died. The mortality rate per 10,000 person-years was 5·85 among individuals with ADHD compared with 2·21 in those without (corresponding to a fully adjusted MRR of 2·07, 95% CI 1·70-2·50; p<0·0001). Accidents were the most common cause of death. Compared with individuals without ADHD, the fully adjusted MRR for individuals diagnosed with ADHD at ages younger than 6 years was 1·86 (95% CI 0·93-3·27), and it was 1·58 (1·21-2·03) for those aged 6-17 years, and 4·25 (3·05-5·78) for those aged 18 years or older. After exclusion of individuals with oppositional defiant disorder, conduct disorder, and substance use disorder, ADHD remained associated with increased mortality (fully adjusted MRR 1·50, 1·11-1·98), and was higher in girls and women (2·85, 1·56-4·71) than in boys and men (1·27, 0·89-1·76).


CONCLUSIONS
ADHD was associated with significantly increased mortality rates. People diagnosed with ADHD in adulthood had a higher MRR than did those diagnosed in childhood and adolescence. Comorbid oppositional defiant disorder, conduct disorder, and substance use disorder increased the MRR even further. However, when adjusted for these comorbidities, ADHD remained associated with excess mortality, with higher MRRs in girls and women with ADHD than in boys and men with ADHD. The excess mortality in ADHD was mainly driven by deaths from unnatural causes, especially accidents.


BACKGROUND
This study was supported by a grant from the Lundbeck Foundation.
National Centre for Register-Based Research, Department of Economics and Business, School of Business and Social Sciences, Aarhus University, Aarhus, Denmark; The Lundbeck Foundation Initiative for Integrative Psychiatric Research, iPSYCH, Aarhus and Copenhagen, Denmark; Centre for Integrated Register-Based Research at Aarhus University (CIRRAU), Aarhus, Denmark; Department for Child and Adolescent Psychiatry, Hospital of Telemark, Kragerø, Norway. Electronic address: sdalsgaard@econ.au.dk.
Søren
S
Dalsgaard
The Lundbeck Foundation Initiative for Integrative Psychiatric Research, iPSYCH, Aarhus and Copenhagen, Denmark; Research Department P, Aarhus University Hospital-Risskov, Risskov, Denmark.
Søren Dinesen
SD
Østergaard
Child Study Center, Yale University School of Medicine, New Haven, CT, USA.
James F
JF
Leckman
National Centre for Register-Based Research, Department of Economics and Business, School of Business and Social Sciences, Aarhus University, Aarhus, Denmark; The Lundbeck Foundation Initiative for Integrative Psychiatric Research, iPSYCH, Aarhus and Copenhagen, Denmark; Centre for Integrated Register-Based Research at Aarhus University (CIRRAU), Aarhus, Denmark.
Preben Bo
PB
Mortensen
National Centre for Register-Based Research, Department of Economics and Business, School of Business and Social Sciences, Aarhus University, Aarhus, Denmark; The Lundbeck Foundation Initiative for Integrative Psychiatric Research, iPSYCH, Aarhus and Copenhagen, Denmark.
Marianne Giørtz
MG
Pedersen
D000059:Accidents / Q000706:statistics & numerical data; D000293:Adolescent; D000328:Adult; D017668:Age of Onset; D001289:Attention Deficit Disorder with Hyperactivity / Q000401:mortality*; D019958:Attention Deficit and Disruptive Behavior Disorders / Q000453:epidemiology; D016022:Case-Control Studies; D002423:Cause of Death / Q000639:trends*; D002648:Child; D002675:Child, Preschool; D019955:Conduct Disorder / Q000453:epidemiology; D003430:Cross-Sectional Studies; D003718:Denmark / Q000453:epidemiology; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D016012:Poisson Distribution; D012307:Risk Factors; D019966:Substance-Related Disorders / Q000453:epidemiology; D055815:Young Adult