Occasionally insurance companies make doctors fill out forms for medications not on their formularies, and on the form will be a statement that asks the doctor to check a box if a ‘standard review timeline’ of 72 hours might seriously ‘jeopardize the life or health of the enrollee’.
In the past, I paused to wonder if such a delay would really matter.
Then I read “Mortality in children, adolescents, and adults with attention deficit hyperactivity disorder: a nationwide cohort study” by Soren Dalsgaard et al, in the Lancet in 2015. http://www.sciencedirect.com/science/article/pii/S0140673614616846
This study (with no pharmaceutical industry funding) followed 1.92 million Danish individuals for 24.9 million person-years, and found a mortality risk ratio of 2.07 for individuals with ADHD. Accidents were the most common cause of death. The rates were far higher in those diagnosed after the age of 18 than in those diagnosed from 6 to 17. The mortality risk, surprisingly, was higher in girls and women than in boys and men.
This was the first study to show that ADHD doubled a patient’s risk of death. As Stephen Faraone put it in his accompanying editorial: “Although no single study can be definitive, this one comes close. The data come from the medical registers of Denmark, where diagnoses of ADHD are conservative. The sample was large—1·92 million people, of whom 32 061 had ADHD—and the follow-up was long, with little missing data. Most importantly, the authors adjusted for potential confounders.”
Why the increased accidents? One possibility is that people with ADHD have increased sensation seeking (SS). “SS refers to a personality trait marked by the proclivity to seek out experiences that are novel, varied, complex, and intense” (page 180). Another is that they have problems with “effortful control” processes that result in lapses of concentration or working memory. http://www.sciencedirect.com/science/article/pii/S0140673614618225
A patient recently told me a story that brought the concept of ADHD-induced accidents to life for me. He had started Adderall close to the age of 30, after his previous physician had advised him to take a low dose consistently. On the routine Adderall, he had been able to finish his thesis, get married, and obtain a job, all in rapid succession. (He previously had used Adderall intermittently to cram for exams.) When he tried to taper off Adderall, his list of incomplete chores grew, producing more anxiety and frustration. He went back on it and has stayed on the same low dosage for the last 6 years.
At our first visit, about six years ago, he reported he had had surgeries on both knees, his wrist, and his hand, due to accidents suffered doing vigorous outdoor sports such as surfing, rockclimbing, and mountain biking.
I saw him again in early June, 2017. He continued to do well, and the Adderall continued to be helpful, at the same modest dosage: “If I don’t stay on it, work won’t happen”.
But, he reported, there had been a remarkable change in the frequency of his accidents and surgeries. “I had about one orthopedic surgery/year from my teens to my late twenties: both knees, both elbows, multiple broken wrists, and multiple concussions, because of my risk-taking behavior. Now I’m less apt to carelessly throw myself off something”. His last major injury had occurred one year before he started Adderall, when he broke his wrist.
He ascribes the difference to his ability to perceive risk.
“Wow,” I said. “That’s an amazing change. It’s really impressive. But please,” I begged, “please wear your helmet when you ride your bike.”