518240

research-article2014
JADXXX10.1177/1087054713518240Journal of Attention DisordersPieiro-Dieguez et al.

Article
Journal of Attention Disorders

Psychiatric Comorbidity at the Time

2016, Vol. 20(12) 10661075
The Author(s) 2014
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DOI: 10.1177/1087054713518240

The CAT Study jad.sagepub.com

Benjamn Pieiro-Dieguez1, Vicent Balanz-Martnez2, Pilar Garca-Garca3,

Begoa Soler-Lpez4, and the CAT Study Group5

Abstract
Objective: The CAT (Comorbilidad en Adultos con TDAH) study aimed to quantify and characterize the psychiatric
comorbidity at the time of diagnosis of ADHD in adult outpatients. Method: Cross-sectional, multicenter, observational
register of adults with ADHD diagnosed for the first time. Results: In this large sample of adult ADHD (n = 367), psychiatric
comorbidities were present in 66.2% of the sample, and were more prevalent in males and in the hyperactive-impulsive
and combined subtypes. The most common comorbidities were substance use disorders (39.2%), anxiety disorders (23%),
and mood disorders (18.1%). In all, 88.8% patients were prescribed pharmacological treatment for ADHD (in 93.4% of
cases, modified release methylphenidate capsules 50:50). Conclusion: A high proportion of psychiatric comorbidity was
observed when adult outpatients received a first-time diagnosis of ADHD. The systematic registering of patients and
comorbidities in clinical practice may help to better understand and manage the prognostic determinants in adult ADHD.
(J. of Att. Dis. 2016; 20(12) 1066-1075)

Keywords
register, outcome, ADHD treatment, psychiatric comorbidity, adulthood

Introduction
ADHD in adults is a complex condition which sparks partic-
ular interest in different medical, social, academic, cultural,
and economic areas given its impact during patients life
(Gibbins & Weiss, 2007; Klein etal., 2012; Kooij etal., 2010;
Laufktter, Eichhammer, & Hajak, 2004; Matheson etal.,
2013; Waite, 2010). Quality of life in these patients is affected
by the impact of this condition on family, education, and
employment, as well as a higher rate of accidents and foren-
sic or criminal issues (Goksyr & Nttestad, 2008; Ramos-
Quiroga etal., 2006; Weiss, Hetchman, Milroy, & Perlman,
2003). The negative impact of ADHD on quality of life and
functioning persists into middle to late adulthood (Das,
Cherbuin, Butterworth, Anstey, & Easteal, 2012; Gjervan,
Torgersen, Nordahl, & Rasmussen, 2012; Lensing, Zeiner,
Sandvik, & Opjordsmoen, 2015). Moreover, the burden of
illness is similarly relevant across several Western countries
(Brod, Pohlman, Lasser, & Hodgkins, 2012). All these fac-
tors mean that ADHD in adult patients results in a high costs
to economy and health (Bernfort, Nordfeldt, & Persson,
2008; Hodgkins, Montejano, Sasan, & Huse, 2011; Kessler
etal., 2005, Kessler, Lane, Stang, & Van Brunt, 2009).
Although some adults with ADHD were diagnosed during
childhood, for many others, the condition may not be detected
until adulthood (Gibbins & Weiss, 2007), and this delay in
diagnosis and access to treatment is thought to worsen the out-
comes. According to available studies, it is known that only
25% of adults referred with possible ADHD were diagnosed
during childhood or adolescence (Faraone, Spencer, Montano,
& Biederman, 2004). In this regard, there is a high genetic
factor involved in ADHD, and its heritability has been esti-
mated to be around 0.76 (Faraone, Perlis, etal., 2005). In fact,
some adults with ADHD are referred for the first time after
their children has been diagnosed with ADHD (Harvey,
Danforth, McKee, Ulaszek, & Friedman, 2003). Therefore,
ADHD may currently be considered an underdiagnosed and
1
Hospital de Terrassa (Consorci Sanitari CST), Servicio de Psiquiatra,
Terrassa (Barcelona), Spain
2
Servicio de Psiquiatra, Hospital Universitari Doctor Peset, Universitat
de Valncia, FISABIO, CIBERSAM, Valencia, Spain
3
Department of Biomedical Science (Area of Pharmacology), University
of Alcal, Alcal de Henares, Madrid, Spain
4
Medical DepartmentD, E-C-BIO S.L. Madrid, Spain
5
See Authors Note
Corresponding Author:
Pilar Garca-Garca, Departament of Biomedical Science (Area of
Pharmacology), Avda San Pablo, 27, 28823 Coslada, Madrid, Spain.
Email: pigargarcia@gmail.com

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Pieiro-Dieguez et al. 1067
undertreated disorder in adults (Aragons, Cais, Caballero,
& Piol-Moreso, 2013; Faraone etal., 2004; Rostain &
Ramsay, 2006). For instance, the results of the National
Comorbidity Survey Replication (NCS-R) showed that only
11% of cases of ADHD in adults were treated (Kessler etal.,
2006).
One of the main reasons for this underdiagnosis in adults
may be the high rate of psychiatric comorbidity associated
with the condition, which may mask the main symptoms
(Kooij etal., 2012). An estimated 70% to 75% of adults
with ADHD present at least one concomitant psychiatric
diagnosis (Biederman etal., 1993; Cumyn, French, &
Hechtman, 2009; Kooij etal., 2010; Sobanski etal., 2007).
Furthermore, patients with ADHD present a poorer progno-
sis for the comorbidity (Diler etal., 2007; Klassen, Katzman,
& Chokka, 2010). According to the literature, the most
common comorbidities are anxiety disorders, mood disor-
ders, and substance use disorders (SUDs), with a highly
variable percentage of comorbidity ranging between 15%
and 45% (Biederman etal., 1993; Kessler etal., 2006; Park
etal., 2011).
The prevalence of ADHD in the adult general population
has been estimated at around 2.5% to 3.4% (Fayyad etal.,
2007; Simon, Czobor, Blint, Mszros, & Bitter, 2009).
While a number of different studies on the prevalence and
incidence of ADHD in adults exist in different countries (de
Zwaan etal., 2012; McCarthy etal., 2012; Montejano etal.,
2012) and information on ADHD adult patients in primary
care in Catalonia has been collected (Aragons etal., 2013;
Aragons etal., 2010), as yet no nationwide study has been
completed in Spain. Similarly, despite the frequency of psy-
chiatric comorbidity in adults with ADHD, and the fact that
it is usually the initial reason for referral, few studies have
focused on this issue. As far as we know, no multicenter
studies on the prevalence and the nature of psychiatric
comorbidity in adult ADHD have been performed. For this
reason, the aim of this study was to establish the prevalence,
nature, and number of and risk factors associated with psy-
chiatric comorbidities in ADHD patients diagnosed for the
first time in adulthood.
Method
The CAT (Comorbilidad en Adultos con TDAH) study was
designed as an observational, cross-sectional, multicenter
patient register. The study was approved by the Ethics
Committee at the Clnic I Provincial Hospital in Barcelona
(2011/6367) and classified by the Spanish Medicines
Agency as an observational non-postauthorization study.
All participants agreed to be included in the study and
signed an informed consent document.
The participating sites were National Health Services,
mental health centers or Outpatient clinics (OC), and private
practices interested in the study. The project was publicized
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through the retail network of the sponsor pharmaceutical
company, JUSTE S.A.Q.F.
The patients included were those receiving a first time
diagnosis of ADHD, as per Diagnostic and Statistical
Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR;
American Psychiatric Association, 2000) criteria. Patients
were consecutively recruited from those attending appoint-
ments at the sites, between April and November 2011. The
inclusion criteria were as follows: patients above 18 receiv-
ing a first diagnosis of ADHD who provided a minimum set
of data: date of first ADHD diagnosis, date of birth, and
gender. No exclusion criteria were established. We did not
consider lifelong comorbidity because detailed psychiatric
history during childhood was not available in all cases, and
we aimed to avoid overweighting the prevalence rate of
comorbidities.
The patient data were taken from their medical records
and included on a restricted-access electronic database. To
calculate the proportion of new cases of ADHD in adults
attending appointments involved in the study, we used the
register of the number of patients treated during the study
period and the start and finish dates for patient inclusion.
Clinical records included data regarding psychiatric
comorbidities, together with those present at the time the
diagnosis was made. Demographic and social information
was recorded, including birth date, sex, marital status, fam-
ily composition, educational and employment status, and
employment skills and economic level. Moreover, history
of tobacco, alcohol and substance use, family history of
psychiatric conditions, and personal history of self-injury
were also recorded. Treatments were classified in three
groups: medications for ADHD, medications for psychiatric
comorbidities, and nonpharmacological treatments.
The study did not require specific pharmacological treat-
ments; the patients selected for the study received treatment
and/or medical care as deemed necessary by their doctors,
for example, under naturalistic conditions.
No formal calculation of sample size was completed. We
summarize qualitative variables by using a frequency distri-
bution. Data were expressed through mean and confidence
intervals of 95%For categorical variables, the exact
Fisher test or the chi-square test (2) was used. For quantita-
tive variables, the Students t test and single factor analyses
of variance were used, with Bonferroni or GamesHowell
corrections. The statistically significant criterion was estab-
lished at p < .05. For all the statistical analysis, the SPSS
program was used (Version 14.0, SPSS Inc., Chicago, IL,
USA).
Results
Seventy-six researchers took part in the CAT study. Of
them, 14 (18.4%) enrolled patients from outpatient clinics
at hospitals, 44 (57.9%) from mental health centers, and 18
1068 Journal of Attention Disorders 20(12)
(23.7%) from private practices. The participating sites
enrolled a mean of 6 patients (range = 2-11).
Description of the Sample
Of the total number of patients included in the study (n =
416), 49 cases were excluded, as the diagnosis of ADHD
was made prior to the start of the study. The final sample
size was therefore 367 patients. The data collected showed
a proportion of 12.8% of adult ADHD for every 100 patients
attending practice. The greatest percentage of ADHD diag-
noses were found in hospitals (25.7%, 95% confidence
interval [95% CI] = [3.3, 48.2]) although there were no sta-
tistically significant differences with the other sites (SC:
9.5%, 95% CI = [3.5, 15.5]; P: 12.6%, 95% CI = [0.7,
24.6]). The study involved a predominantly male sample (n
= 265; 72.6%). The mean age at the time of diagnosis was
32.7 (95% CI = [31.6, 33.8]) with a median of 31.8 years
(18-65). No differences in age by gender or ADHD subtype
were observed.
The most common ADHD subtype was the combined
(ADHD-C; n = 152, 42.1%), followed by the hyperactive-
impulsive (ADHD-H; n = 112; 31%) and the inattentive
(ADHD-I; n = 97; 26.9%) subtypes. No specific subtype
could be established at the time the diagnosis in 6 cases
(1.6%). Compared with men, women presented predomi-
nantly ADHD-I (38% vs. 2.8%, respectively, p = .014).
There were no differences in the gender ratios of the other
two subtypes (Table 1).
Primary education was the academic level reached by
most of the patients with ADHD-C and ADHD-H, versus
ADHD-I (p < .001). A greater proportion of patients with
ADHD-I tended to complete secondary and higher educa-
tion than patients with the other two subtypes of ADHD (p
< .0001). A higher proportion of patients with ADHD-I had
never worked (p = .004), compared with the other two sub-
types. A greater proportion of patients with ADHD-H were
unemployed compared with those with ADHD-I (p < .05).
Patients with ADHD-I were better qualified for employ-
ment (p = .004) than patients with the other two subtypes.
Low and mid-low economic levels were less common in
patients with ADHD-I versus the other two subtypes (p <
.0001); whereas mid level was more frequent in ADHD-H
(p < .0001), mid-high level was more common among
patients with the other two subtypes of ADHD (p < .0001)
(Table 1).
Prevalence of Psychiatric Comorbidity at the
Time of Diagnosis
The type of psychiatric disorder diagnosed prior to the first
appointment was recorded, together with the date of detec-
tion. Most patients (n = 243; 66.2%) had at least one comor-
bid psychiatric condition. The frequency of psychiatric
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comorbidity was similarly distributed by gender (65.7%
males vs. 67% females). The group of patients with
ADHD-C presented psychiatric comorbidity at the time of
diagnosis (72.4%) in a greater proportion (p = .006) than
patients with ADHD-I (53.6%), with no difference versus
patients with ADHD-H (69.6%).
Number of Psychiatric Comorbidities at the Time
of Diagnosis
The study sample presented an average of 2.4 comorbidities
(95% CI = [2.2, 2.5]) with a median of two comorbidities
(ranging from 1 to 8). In the subsample of patients with psy-
chiatric comorbidities, the mean number of comorbidities
was significantly greater in males, 2.5 comorbidities (95%
CI = [2.28, 2.7]), versus females, 2.0 (95% CI = [1.67,
2.33]); p = .014, as well as in patients with ADHD-H (2.4,
95% CI = [2.1, 2.8]; p = .021) and ADHD-C (2.6, 95% CI =
[2.3, 2]; p < .001) versus patients with ADHD-I (1.8, 95%
CI = [1.6, 2.1]; Figure 1).
Type of Psychiatric Comorbidities at the Time of
Diagnosis
The presence of antisocial personality disorder was signifi-
cantly more common in patients with ADHD-H in compari-
son with patients with ADHD-I (p = .023). SUDs, including
nicotine, alcohol, cocaine, and others, were significantly
more common in the ADHD-C compared with the other two
ADHD subtypes (p < .05). Grouped by types of psychiatric
disorders, it was observed that both conduct disorders (p =
.012) and SUDs (p < .0001) were significantly more com-
mon in patients with ADHD-H and ADHD-C compared
with patients with ADHD-I (Figure 2, Table 2).
Comparison of Patients With and Without
Psychiatric Comorbidity
The subsample with psychiatric comorbidities lived with
family members (73.3% vs. 83.6%; p < .05) and had educa-
tion levels up to the end of high school (9.2% vs. 17.9%; p
< .05) less often than those without comorbidities.
The proportion of patients who had never worked was
greater among those without psychiatric comorbidity
(26.9% vs. 11%; p < .05). Temporary and permanent inca-
pacity to work and a lower socioeconomic level were more
common among patients with psychiatric comorbidity
(8.9% vs. 2.5% and 5.1% vs. 0.8%, 13.1% vs. 5.7%,
respectively; all p < .05). Current or past consumption of
alcohol (21.9% vs. 12.5%, and 28.3% vs. 12.5%, p < .05)
or substances (36.7% vs. 22% and 20.4% vs. 10.6%, p <
.05) was significantly more common among patients with
psychiatric comorbidity at the time of diagnosis. Current
Pieiro-Dieguez et al. 1069

Table 1. Sociodemographic Description of the Sample According to ADHD Subtypes (n = 367 Patients).

Subtype of ADHD

ADHD-I ADHD-H ADHD-C Total

n % n % n % n %
Sex
Male 59 60.8 86 76.8 114 76.0 259 72.1
Female 38 39.2 26 23.2 36 24.0 100 27.9
Marital status
Single 58 60.4 76 67.9 84 56.0 218 60.9
Married 33 34.4 26 23.2 48 32.0 107 29.9
Separated/divorced 5 5.2 10 8.9 17 11.3 32 8.9
Widower 0 0 0 0 1 0.7 1 0.3
Family structure
Living alone 10 10.6 23 20.7 25 16.6 58 16.3
Living with family 78 83.0 80 72.1 116 76.8 274 77.0
Living with others 6 6.4 7 6.3 7 4.6 20 5.6
Living in institution 0 0 1 0.9 3 2.0 4 1.1
Educational status
No formal education 0 0 5 4.5 3 2.0 8 2.3
Primary education 8 8.2 46 41.8 53 35.8 107 30.1
Secondary education 17 17.5 25 22.7 33 22.3 75 21.1
High school 24 24.7 7 6.4 13 8.8 44 12.4
Professional training 22 22.7 22 20.0 30 20.3 74 20.8
Higher education 26 26.8 5 4.5 16 10.8 47 13.2
Employment status
Has never worked 24 26.1 10 9.2 20 13.4 54 15.4
Unemployed 19 20.7 47 43.1 49 32.9 115 32.9
Temporary disability 2 2.2 8 7.3 14 9.4 24 6.9
Permanent disability 3 3.3 4 3.7 6 4.0 13 3.7
Housework 2 2.2 3 2.8 1 0.7 6 1.7
Employed 42 45.7 37 33.9 59 39.6 138 39.4
Employment skills
Unskilled 39 44.8 69 67.0 91 63.6 199 59.8
Skilled 48 55.2 34 33.0 52 36.4 134 40.2
Economic level
Low 2 2.1 20 18.3 14 9.3 36 10.2
Mid-low 20 21.3 44 40.4 55 36.7 119 33.7
Mid 46 48.9 33 30.3 65 43.3 144 40.8
Mid-high 23 24.5 11 10.1 13 8.7 47 13.3
High 3 3.2 1 0.9 3 2.0 7 2.0

tobacco use was also more common among patients with a
history of comorbidity (69.5% vs. 52.8%, p < .05).
History of Family Psychiatric Conditions and Self-
Injury
On the other hand, 202 patients (56.6%) had a history of
psychiatric illness among their first-degree relatives, with
no significant gender differences, and 96 (26.9%) presented
a first-degree family history of ADHD. Males had a greater
proportion of family history of ADHD (29.8% vs. 19.4%
females; p = .047). The rate of patients with family history
of either psychiatric illness or ADHD did not significantly
differ between the three ADHD subtypes. A subset (n = 38;
10.7%) of patients had shown prior suicidal attempts, with
no gender differences (p = .062). Statistically significant
differences were observed (p = .001) in the proportion of
patients presenting suicide attempts, this being greater in
patients with ADHD-H (n = 20; 18.3%) compared with
14 cases (9.7%) in the ADHD-C group.

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1070 Journal of Attention Disorders 20(12)

(n = 294; 90.2%) received just one medication. The most

3 commonly prescribed drug for the treatment of ADHD was
modified release methylphenidate capsules (n = 342;
93.4%), followed by atomoxetine (n = 12; 3.3%) and bupro-
2,5
pion (n = 5; 1.4%). A total of 151 patients (41.1%) were
receiving pharmacological treatment for psychiatric comor-
2
bidities. On average, 1.8 drugs (95% CI = [1.6, 1.9])
between 1 and 7 different oneswere administered.

1,5
Discussion
The main aim of the CAT study was to assess the fre-
1 quency and type of psychiatric comorbidities observed in
adults receiving a de novo diagnosis of ADHD. The per-
centage observed (66.2%) indicates a high proportion of
0,5
concomitant psychiatric conditions, in line with the major-
Sex
ity of data available in the literature (Biederman etal.,
Male
0 Female
1993; Biederman, Newcorn, & Sprich, 1991; Kessler
etal., 2006; Kooij etal., 2010; Sobanski etal., 2007)
ADHD predominantly ADHD hyperactive- Combined ADHD although lower than that observed in other studies
inattentive impulsive (McGough etal., 2005).
Adult ADHD subrype
The types of comorbidities observed, led by SUDs
(39.2%) and followed by anxiety disorders (23%), mood
Figure 1. Number of comorbidities at the time of diagnosis, disorders (18.1%), and personality disorders (14.2%), also
by adult ADHD subtype. converges with previous findings (Barkley & Brown, 2008).
A possible explanation for the high rate of comorbid SUD
may be the patients use of alcohol/substances as a means to
50 relieve the symptoms of ADHD, that is, the self-medication
45 hypothesis (Ohlmeier etal., 2007). However, causal infer-
40
ences are precluded by the cross-sectional design of this
35
30
study.
25 Male The prevalence of anxiety disorder and mood disorder in
20 Female the CAT study is lower than that found previously, for
15 Total instance 30% to 50% of anxiety disorder (Adler & Cohen,
10 2004) and 30% of mood disorder (Biederman, Faraone,
5 Monuteaux, Bober, & Cadogen, 2004). The same holds true
0
regarding comorbid major depressive disorder, which was
observed in 9.7% of our sample, versus 18.6% (Kessler
etal., 2006) or even 40.7% (Biederman etal., 2008). These
differences might be explained by our study only consider-
ing comorbid disorders at the time the diagnosis of ADHD
was made, whereas others involved lifelong comorbidity.
Figure 2. Type of associated psychiatric illness at the time of The frequency of comorbidity with bipolar disorder (2.5%)
diagnosis of ADHD in adult patients. was also lower than 10% to 14% reported in some
(Biederman etal., 1994; Tamam, Karakus, & Ozpoyraz,
2008), but similar to other (Jaideep, Reddy, & Srinath,
Treatments
2006) studies. Comorbidity with antisocial personality dis-
Regarding treatment, 50.4% (n = 185) of patients received order in our study was 3.6%, slightly lower than that previ-
treatment with behavioral therapy and/or psychological ously observed (Mannuzza & Klein, 2000). Borderline
support, add-on to pharmacological treatment in all cases. personality disorder, observed primarily in women (15%)
Moreover, 358 patients (97.6%) received pharmacological presented a similar level of frequency to that found by other
treatments and 12.5% also received treatments for comor- authors (14% in Fischer, Barkley, Smallish, & Fletcher,
bid conditions. Most patients (n = 326; 88.8%) were receiv- 2002). Collectively, the different methodologies used may
ing pharmacological treatment for ADHD, and most explain the lower prevalence of the majority of common

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Pieiro-Dieguez et al. 1071

Table 2. Distribution of Psychiatric Comorbidities by Gender and ADHD Subtype.

Subtype of ADHD gender

ADHD-I ADHD-H ADHD-C Total Male Female

Psychiatric disorder n (%) n (%) n (%) n (%) n (%) n (%) p

Anxiety disorders 29 (29.9) 25 (22.3) 30 (19.7) 84 (23.3) 59 (22.3) 25 (25.0)
Generalized anxiety disorder 22 (22.7) 22 (19.6) 21 (13.8) 65 (18.0) 44 (16.6) 20 (20.0)
Social phobia 4 (4.1) 1 (0.9) 2 (1.3) 7 (1.9) 4 (1.5) 3 (3.0)
Agoraphobia 0 1 (0.9) 3 (2.0) 4 (1.1) 3 (1,1) 1 (1.0)
Other phobias 0 1 (0.9) 0 1 (0.3) 1 (0.4) 0
Obsessive-compulsive disorder 6 (6.2) 3 (2.7) 9 (5.9) 18 (5.0) 16 (6.0) 3 (3.0)
Posttraumatic stress disorder 0 1 (0.9) 0 1 (0.3) 0 1 (1.0)
Mood disorders 18 (18.6) 16 (14.3) 33 (21.7) 67 (18.6) 43 (16.2) 23 (23.0)
Major depressive disorder 8 (8.2) 10 (8.9) 17 (11.2) 35 (9.7) 19 (7.2) 15 (15.0) .022
Dysthymic disorder 6 (6.2) 4 (3.6) 14 (9.2) 24 (6.6) 17 (6.4) 7 (7.0)
Bipolar disorder 4 (4.1) 2 (1.8) 3 (2.0) 9 (2.5) 7 (2.6) 2 (2.0)
Conduct disorders 1 (1.0) 13 (11.6) 14 (9.2) 28 (7.8) 26 (9.8) 3 (3.0) .0001
Conduct disorder 1 (1.0) 10 (8.9) 6 (3.9) 17 (4.7) 17 (6.4) 1 (1.0) .033
Oppositional defiant disorder 0 3 (2.7) 5 (3.3) 8 (2.2) 7 (2.6) 1 (1.0)
Other disruptive behavior disorders 0 0 3 (2.0) 3 (0.8) 2 (0.8) 1 (1.0)
Eating disorders 1 (1.0) 9 (8.0) 7 (4.6) 17 (4.7) 3 (1.1) 14 (14.0) .0001
Bulimia nervosa 1 (1.0) 7 (6.3) 6 (3.9) 14 (3.9) 3 (1.1) 11 (11.0) .0001
Anorexia nervosa 0 2 (1.8) 1 (0.7) 3 (0.8) 0 3 (3.0) .005
Personality Disorders 8 (8.2) 18 (16.1) 26 (17.1) 52 (14.4) 32 (12.1) 20 (20.0)
Schizoid 0 0 1 (0.7) 1 (0.3) 1 (0.4) 0
Antisocial 0 3 (2.7) 10 (6.6) 13 (3.6) 11 (4.2) 1 (1.0)
Borderline 4 (4.1) 11 (9.8) 9 (5.9) 24 (6.6) 10 (3.8) 15 (15.0) .0001
Histrionic 0 2 (1.8) 3 (2.0) 5 (1.4) 2 (0.8) 3 (3.0)
Narcissistic 1 (1.0) 1 (0.9) 1 (0.7) 3 (0.8) 3 (1.1) 0
Dependent 0 0 1 (0.7) 1 (0.3) 1 (0.4) 0
Avoidant 3 (3.1) 1 (0.9) 2 (1.3) 6 (1.7) 4 (1.5) 2 (2.0)
Substance-related disorders 17 (17.5) 46 (41.1) 81 (53.3) 144 (39.9) 116 (43.8) 27 (27.0) .003
Nicotine 10 (10.3) 24 (21.4) 45 (29.6) 79 (21.9) 60 (22.6) 18 (18.0)
Alcohol 7 (7.2) 27 (24.1) 44 (28.9) 78 (21.6) 68 (25.7) 9 (9.0) .001
Cocaine 7 (7.2) 30 (26.8) 38 (25.0) 75 (20.8) 67 (25.3) 8 (8.0) .0001
Opioids 0 3 (2.7) 12 (7.9) 15 (4.2) 15 (5.7) 0 .015
Amphetamines 0 5 (4.5) 4 (2.6) 9 (2.5) 9 (3.4) 1 (1.0)
Other substances 3 (3.1) 12 (10.7) 18 (11.8) 33 (9.1) 30 (11.3) 3 (3.0) .013
Learning and communication disorders 3 (3.1) 1 (0.9) 1 (0.7) 5 (1.4) 4 (1.5) 2 (2.0)
Reading disorder 2 (2.1) 1 (0.9) 1 (0.7) 4 (1.1) 4 (1.5) 1 (1.0)
Mathematics disorder 1 (1.0) 1 (0.9) 0 2 (0.6) 1 (0.4) 1 (1.0)
Neurological disorders 5 (5.2) 1 (0.9) 3 (2.0) 9 (2.5) 7 (2.6) 2 (2.0)
Tic disorders 3 (3.1) 0 2 (1.3) 5 (1.4) 3 (1.1) 2 (2.0)
Tourettes disorder 0 0 1 (0.7) 1 (0.3) 0 1 (1.0)
Epilepsy 1 (1.0) 1 (0.9) 1 (0.7) 3 (0.8) 3 (1.1) 0
Other neurological disorders 1 (1.0) 0 0 1 (0.3) 1 (0.4) 0

comorbidities in ours versus other studies; thus our study
did not take into consideration childhood-related comor-
bidities such as oppositional defiant disorder (ODD) or con-
duct disorder. Furthermore, it only considers the conditions
observed at the time of diagnosis and not during the course
of their illness.
As regards the comparison of ADHD subtypes, in conso-
nance with other works, the frequency of psychiatric comor-
bidity was greater in ADHD-C and ADHD-H compared
with ADHD-I, which may suggest greater disability and
poorer functioning, quality of life, and prognosis (Barkley
& Brown, 2008). Further supporting this data, history of

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1072 Journal of Attention Disorders 20(12)
suicide attempts was more common in ADHD-H than in
ADHD-I. Our findings are also consistent with other studies
reporting a tendency toward self-harm in ADHD patients
(James, Lai, & Dahl, 2004).
In line with published data (Biederman etal., 2006), a
greater prevalence of the condition was observed in men
than in women, with a ratio of 2.7:1. Disproportioned gen-
der ratios of 6:1 to 3:1 usually observed during childhood
(Goodyear & Hynd, 1992; Taylor, Sandberg, Thorley, &
Giles, 1991) virtually disappear in adulthood. As indicated
by other authors, this is probably due to a bias in the assess-
ment of symptoms according to gender, as girls more com-
monly present with ADHD-I which results in less disruptive
behavior and means that the disorder is more easily left
undetected and undiagnosed (Biederman etal., 2004; Quinn
etal., 2008). Consistently, a significantly greater percentage
of women than men in the ADHD-I group was found in our
study. Since ADHD-I was associated with the lowest rate of
comorbidities, it is likely that women with ADHD-I present
less often to mental health services. Consequently, this may
favor professionals impression that adult ADHD is far less
prevalent among women.
Although the percentage of patients with comorbidity
did not differ by gender, a higher number of comorbidities
was observed in men compared with women, perhaps
related to the predominant type of ADHD in each gender
group. Moreover, the pattern of comorbidities observed by
gender was different. Major depressive disorder was twice
as common in women, and eating disorders were up to 13
times more common. Borderline personality disorder was
also 4 times more common in women, similar to previous
reports (Fischer etal., 2002; Sprafkin, Gadow, Weiss,
Schneider, & Nolan, 2007). As expected, antisocial person-
ality disorder was more common in men than in women
(6.2% vs. 1%) although with lower percentages than in
other studies (Biederman etal., 2004, 24% vs. 14%).
Overall, the distribution of comorbidities by gender in
the CAT study concurs with those of previous studies,
which also found that women with ADHD are more likely
to present with comorbid eating and mood disorders, while
men with ADHD are more prone to present with comorbid
SUDs (Cumyn etal., 2009; Sobanski etal., 2007).
In our study, the proportion of patients with a de novo
diagnosis was 12.8%, which is much higher than the preva-
lence in the adult general population (Faraone & Biederman,
2005; Fayyad etal., 2007; Kessler etal., 2006; Simon etal.,
2009) but closer to that of studies based on clinical samples
(18%, Almeida Montes, Hernndez Garca, & Ricardo-
Garcell, 2007; 21.6%, Nylander, Holmqvist, Gustafson, &
Gillberg, 2009).
It should be noted that more than half of adult ADHD
patients in the CAT study reported to have a positive family
psychiatric history, with no difference between the genders,
whereas a family history of ADHD was significantly more
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common in males. Bearing in mind the high level of herita-
bility associated with ADHD (Faraone, Perlis, etal., 2005),
professionals working with children and adolescents should
consider an assessment of the disorder in their parents as
part of integral therapy (Psychogiou, Daley, Thompson, &
Sonuga-Barke, 2008) to maximize diagnoses of ADHD in
adults.
Half of the adult patients in the CAT study received
behavioral therapy and most (88.8%) received medications,
primarily with methylphenidate, which was prescribed as
monotherapy in 90.2% of the sample. This represents a very
homogeneous prescription pattern, which is considerably
higher than that obtained in recent studies (11% in Kessler
etal., 2009), and may suggest a change in the treatment of
adults with ADHD.
Nine psychiatric disease registers exist in Spain, yet
none is ADHD specific (Imaz Iglesia, Aibar Remn,
Gonzlez Enrquez, Gol Freixa, & Gmez Lpez, 2005).
Until now, only three studies had focused on the prevalence
of ADHD in psychiatric outpatient settings worldwide
(Almeida etal., 2007; Lomas & Gartside, 1997; Nylander
etal., 2009). Two of them were completed in a single men-
tal health clinic, and the remaining study (Lomas &
Gartside, 1997) was carried out in a veteran center. This
means that the CAT study is the only multicenter, nation-
wide, ADHD-focused study, including a relatively large
sample of psychiatric outpatients.
The limitations of our study include its cross-sectional
design, the retrospective review of clinical records and the
absence of limits in selection criteria. The participation of
most Spanish regions makes it possible to estimate the
results at a national level. However, future studies should
cover the entire country to that end.
To conclude, the use of patient records for the control
and assessment of the prognosis for a condition that, like
ADHD, may persist throughout the patients lifetime. The
high level of psychiatric comorbidity in these patients
means that appointments at mental health centers offer an
excellent opportunity to diagnose cases of ADHD which
would otherwise go undetected, thus negatively affecting
patients outcomes and quality of life. Given the results of
the CAT study, ADHD should be ruled out systematically in
all patients attending psychiatric practices to offer improved
access to the effective treatments currently available. This
seems to be particularly relevant for women with eating and
mood disorder and men with SUD.
Authors Note
In addition to the authors, the following researchers were members
of the CAT Study Group: Moiss Aguilar Domingo; Jose David
Albillo Labarra; Pablo Alvarez Lobato; Alejandro Amor
Salamanca; Jess Ayala Bes; Francisco Javier Barn Fernndez;
Rafael Benito Moraga; Javier Blanco Blanco; Antonio Briones
Perona; Tulio Callorda Boniatti; Jose Miguel Cano Gras; Juan
Pieiro-Dieguez et al. 1073
Manuel Cantos Martnez; Indalecio Carrera Machado; M Cristina
Casal Pena; Carlos Castillo Flores; Carlos Castro Dono; M Teresa
De Lucas Taracena; Begoa De Pablo Garca; Patricia Fadn
Martn; Ernesto Ferrer Gmez Del Valle; Eva Fontova; Facund
Fora Eroles; Rafael Forcada Chapa; Ignacio Gainza Tejedor;
Araceli Gamez Palomares; Javier Garca Campayo; Jose Manuel
Garca Moreno; Xavier Gastaminza Prez; Mara Del Carmen
Gimeno Escrig; Sara Gonzlez Vives; Elisabet Gorgues Queralt;
Alfredo Granell Gonochategui; Alfredo Gurrea Escajedo; Rosario
Gutierrez Labrador; Ana Herrero Mendoza; Federico Guillermo
Iglesias Lorenzo; Miguel Martn Iribarren; German Jurado De
Flores Yepez; Miguel A Lanbadaso Vazquez; Jose M Lomba
Borrajo; Sonia Lpez Arribas; Jose Manuel Manso Garca;
Antonio Marcos Flores; Daniel Martn Fernndez-Mayoralas;
Nicols Martin Navarro; Luis Martn Recuero; Isabel Martnez
Gras; Jose Martnez Raga; Pedro A Megia Lpez; Jose Luis
Montero Horche; Pablo Luis Moreno Flores; Emma Osejo Diago;
Francesco Panicali; Francisco Pascual Pastor; Guillermo Ponce
Alfaro; Santiago Posik Rosati; Marta Puig Sanz; Ana M Ins
Queijero Presa; Carmen Ripoll Alandes; Jose Juan Rodriguez
Solano; Juan Ramon Sambola Bugua; Gemma San Narciso
Izquierdo; Milagros Snchez Garca; Cesar Luis Sanz De La
Garza; Olga Sanz Granado; Francesc Segarra Murla; Pedro Seijo
Ceballos; Olga Sobrino Cabra; Pedro A Sopelana Rodrguez;
Virgilio Traid Sender; Rosario Vacas Moreira; Miguel Angel
Villalba Abarquero; Rosa Villanueva Peri; Laura Villar Mateo;
Diana Zambrano; Jose Miguel Zoido Ramos.
Declaration of Conflicting Interests
The author(s) declared the following potential conflicts of interest
with respect to the research, authorship, and/or publication of this
article: Pilar Garca is contracted by the medical department of
Juste S.A.Q.F. Begoa Soler completed the design, quality con-
trol, and statistical analysis of the study under contract with Juste
S.A.Q.F. The remaining authors hereby declare that they have no
conflicts of interest affecting the aims and results of the study.
Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article: This
work was funded by Juste S.A.Q.F.
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Author Biographies
Benjamn Pieiro-Dieguez, MD, senior staff, Psychiatry
Department of Hospital de Terrassa (Barcelona, Spain, www.cst.
cat). He works in acute psychiatric hospitalization in a General
Hospital since 2002. He has more than 10 years of experience in
diagnostic and treatment of adults with ADHD, and he was direc-
tor and author of the online workshop The attention deficit disor-
der (ADHD). Evolution throughout life and its comorbidities.
Vicent Balanz-Martnez, MD, PhD, has held the position of
associate professor of psychiatry at the University of Valencia
(Spain) since 2005, and is a senior researcher of the Centro de
Investigacin Biomdica in Red de Salud Mental (CIBERSAM).
He is currently the director of the Community Mental Health Unit
in Catarroja, Spain. His research interests are the identification of
neurocognitive endophenotypes in severe psychiatric disorders
and innovative treatments from a clinical staging perspective. He
has published more than 40 peer-reviewed articles in international
journals and 25 book chapters.
Pilar Garca-Garca, PharmD, PhD, works in Scientific-Medical
Departamento of Juste S.A.Q.F. since 2000. She has collaborated at
University Camilo Jos Cela (professor associate) and at University
of Alcal (professor honorific). Her research is focused in psycho-
pharmacology, nutrition, and pharmacovigilance. She published 24
articles in international journals and 14 book chapters.
Begoa Soler-Lpez, MD, is medical director of the Clinical
Research Organization E-C-BIO, S.L. (Madrid, Spain, www.
ecbio.net). She founded the company in 1997. She is a senior med-
ical adviser and statistician, with more than 20 years of experience
in clinical research in different international companies and sev-
eral therapeutical areas. Her research is focused in public health.
She published 23 articles in journals indexed in PubMed.
The CAT (Comorbilidad en Adultos con TDAH: Comorbidity in
adult with ADHD) study: 78 Spanish physicians took part in this
study: psychiatrists, neurologists, and doctors specialists in addic-
tive disorders.