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LETTERS TO EDITOR  
Year : 2020  |  Volume : 62  |  Issue : 4  |  Page : 449-450
Clinical features and suicidal behavior in major depression with comorbid attention-deficit hyperactivity disorder


Department of Psychiatry, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India

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Date of Submission03-Feb-2020
Date of Decision18-May-2020
Date of Acceptance21-Jun-2020
Date of Web Publication27-Jul-2020
 

How to cite this article:
Menon V, Biyyala D, Mukherjee MP. Clinical features and suicidal behavior in major depression with comorbid attention-deficit hyperactivity disorder. Indian J Psychiatry 2020;62:449-50

How to cite this URL:
Menon V, Biyyala D, Mukherjee MP. Clinical features and suicidal behavior in major depression with comorbid attention-deficit hyperactivity disorder. Indian J Psychiatry [serial online] 2020 [cited 2020 Aug 8];62:449-50. Available from: http://www.indianjpsychiatry.org/text.asp?2020/62/4/449/291010




Sir,

Delibas et al.[1] compared suicidality, onset, and severity of depression between adult inpatients with major depressive disorder (MDD) with or without a comorbid diagnosis of attention-deficit hyperactivity disorder (ADHD). They found that depression begins earlier in patients with comorbid ADHD and that this group had increased lifetime suicidal behaviors compared to depressed subjects without comorbid ADHD. We raise a few arguments which we believe are crucial to put the study results in the right perspective:

  1. For starters, the nosological status of a diagnosis of adult ADHD continues to be debated. Whereas proponents argue for the existence of a spontaneous “late onset” ADHD,[2] the naysayers suggest that many such cases are a result of “late identification” and not, “late onset.”[3] This being a cross-sectional study, it is not possible to ascertain which disease condition (MDD or ADHD) occurred first. However, the Wender–Utah rating scale, which the authors have used, assesses childhood ADHD symptoms. It can therefore be surmised that, in this sample, all adult ADHD cases represented those with symptom continuation from childhood and adolescence. Given this fact, we argue that the author's major finding about earlier age of onset of depression in those with depression and concurrent ADHD may actually be a methodological artefact, because ADHD symptoms usually start earlier in life than depression and depression is commonly comorbid with ADHD [4]
  2. We are also concerned that the authors have not defined a suicide attempt, their major outcome variable, anywhere in the text of the paper. In fact, [Table 3] in the paper clearly indicates the operational definition of attempt employed - attempts requiring medical attention. This definition is not a standard one. It is more suitable for medically serious attempts and clearly excludes attempts at the lower end of the severity spectrum
  3. When study groups are matched for certain variables (in this case, age and gender), comparing the same parameters between groups ([Table 1] in the paper), without providing adequate justification, appears redundant. Equally superfluous are the comparison of variables such as total ADHD score, number of ADHD criteria, and ADHD rating scale scores between groups divided on the basis of a diagnosis of ADHD.


A relatively minor, yet significant, issue in the context of the study hypothesis is the lack of statistical correction for multiple comparisons of related suicidal constructs ([Table 3] in the paper), an approach that has been previously recommended.[5] After applying a Bonferroni correction (0.05/3 = 0.017), lifetime suicidal ideation would no longer be different between groups.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Delibas DH, Erdogan E, Gulseren S. Evaluation of clinical and suicidal behavior characteristics among urban, Turkish middle-age depressive patients with comorbid attention deficit hyperactivity disorder. Indian J Psychiatry 2019;61:612-7.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Moffitt TE, Houts R, Asherson P, Belsky DW, Corcoran DL, Hammerle M, et al. Is adult ADHD a childhood-onset neurodevelopmental disorder? Evidence from a four-decade longitudinal cohort study. Am J Psychiatry 2015;172:967-77.  Back to cited text no. 2
    
3.
Solanto MV. Child vs. adult onset of attention-deficit/hyperactivity disorder. JAMA Psychiatry 2017;74:421.  Back to cited text no. 3
    
4.
Katzman MA, Bilkey TS, Chokka PR, Fallu A, Klassen LJ. Adult ADHD and comorbid disorders: Clinical implications of a dimensional approach. BMC Psychiatry 2017;17:302.  Back to cited text no. 4
    
5.
Menon V. Multiple testing and protection against Type I error using P value correction: Application in cross-sectional study designs. Indian J Psychol Med 2019;41:197.  Back to cited text no. 5
[PUBMED]  [Full text]  

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Correspondence Address:
Vikas Menon
Department of Psychiatry, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/psychiatry.IndianJPsychiatry_90_20

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