Attention deficit hyperactivity disorder in prison inmates

Background: Attention deficit hyperactivity disorder (ADHD) is an inherited developmental disorder with early onset, chronically persisting in the vast majority of cases. ADHD is associated with pervasive cognitive, emotional and functional impairments, as well as an increased rate of coexisting disorders. ADHD in the presence of early disruptive behaviours increase the risk for later delinquency. ADHD is estimated to be present in about 25-45% of adult prison inmates, thus 10-times increased relative to the general population. Despite this, pharmacological treatment for ADHD has not previously been evaluated in prison inmates.

Aims: The aims of the present thesis were to characterise symptoms and impairments of adult male long-term prison inmates with ADHD, and to evaluate the efficacy, safety and tolerability of osmotic release oral system methylphenidate (OROS-MPH) provided to adult male prison inmates with ADHD and coexisting disorders as compared to placebo. An additional aim was to evaluate the long-term effectiveness of OROS-MPH when delivered alongside regularly provided psychosocial interventions within a prison setting.

Methods: Following an initial screening procedure at Norrtälje Prison, Sweden, extensive diagnostic evaluations were undertaken in 34 inmates indicating ADHD by the screening. Subsequently, 30 inmates out of 34 that confirmed ADHD and coexisting disorders were enrolled to a 5-week randomised, double-blind, placebo-controlled, fixed-dose trial of OROS-MPH followed by a 47-week open- label, flexible-dosing extension.

Results: ADHD was estimated to be present in about 40% of adult male long-term inmates of Norrtälje Prison. Inmates with ADHD were severely symptomatic and functionally impaired when compared to psychiatric outpatients with ADHD and with controls. OROS-MPH was highly effective and overall safe, both in the short- term relative to placebo (Cohen’s d=2.17; Number needed to treat=1.1), and in the long-term when provided alongside psychosocial interventions. The placebo response was non-significant. By the primary end-point, 87% of participants receiving OROS-MPH had achieved ≥ 30% improvement in ADHD symptoms evaluated by the investigator-rated CAARS: O-SV scale, thus defined as treatment responders. On the other hand, 40% were defined to be in full remission by achieving normalisation of CAARS: O-SV scores when compared to a norm population without ADHD. Overall, symptomatic improvements translated into functional improvements. A few predictors of treatment response are suggested.

Conclusions: ADHD is a prevalent, persistent and impairing disorder in adult male long-term prison inmates. Treatment with OROS-MPH appears to be associated with a robust positive response in this specific group of long-term prison inmates with ADHD and coexisting disorders.

List of scientific papers

I. Ginsberg Y, Hirvikoski T, Lindefors N (2010). Attention Deficit Hyperactivity Disorder (ADHD) among longer-term prison inmates is a prevalent, persistent and disabling disorder. BMC Psychiatry. 10:112.
https://doi.org/10.1186/1471-244X-10-112

II. Ginsberg Y, Lindefors N (2012). Methylphenidate treatment of adult male prison inmates with attention-deficit hyperactivity disorder: randomised double-blind placebo-controlled trial with open-label extension. The British Journal of Psychiatry. 200: 68–73.
https://doi.org/10.1192/bjp.bp.111.092940

III. Ginsberg Y, Hirvikoski T, Grann M, Lindefors N. Long-term functional outcome in adult prison inmates with ADHD receiving OROS-methylphenidate. [Accepted]
https://doi.org/10.1007/s00406-012-0317-8

IV. Ginsberg Y, Grann M, Lindefors N. Predictors of treatment response to OROS-methylphenidate in adult prison inmates with attention-deficit/hyperactivity disorder. [Submitted]