We have read with interest the article by Pauly et al. 1, describing the use of methylphenidate and coprescribed psychotropic medications in children and adults in a four million population in France.
The authors observed that incident prescription of methylphenidate was frequently associated with other psychotropic drugs in adults and particularly in above 25-year-old individuals. They also highlighted a frequent short-term treatment discontinuation in adults, with a 1-year treatment continuation rate less than 50%. To interpret these findings, the authors suggested that there is a high rate of misuse of methylphenidate by non-ADHD patients and that patients treated are mostly those with comorbidities.
We are in agreement with the authors about their caution regarding the risk of abuse, especially in specific populations as suggested by the frequency of coprescription of drugs at risk for recreational use (morphine sulphate, flunitrazepam, anticholinergic agents). Similarly, the high rate of coprescribed psychotropic drugs is not surprising regarding the high rate of psychiatric comorbidities in adults with ADHD (estimated at 80%).
However, we believe there are important elements missing. To interpret these findings from a French population, it is necessary to take into account the situation of the management of ADHD in adults in France. There is still a low expertise in diagnosing and managing ADHD in this population due to the absence of physicians training and the lack of reference centers for adult ADHD in university hospitals. French adult patients often encounter major difficulty to obtain access to professionals with ADHD skills, with medical monitoring being reduced, which has a definite impact on compliance.
This French specificity may lead to a low use of methylphenidate compared to other European countries, by a factor of one tenth 2, whereas the prescriptions of other psychotropic drugs are at a high level, as acknowledged by the authors. It may also explain the high frequency of methylphenidate discontinuation in adults, being largely higher than in other European countries 3.
The authors mentioned that 42% of 18- to 24-year-old users were students, reflecting a potential high frequency of misuse by non-ADHD students, for cognitive enhancement or partying. However, a recent French survey indicated that only 1.5% of French medical students reported consuming at least once methylphenidate 4. It also can be hypothesized that ADHD can lead to a greater functional impairment in students, a condition that increase the need for medication in this population in comparison with nonstudents. The short-term prescription in this population may relate to the punctual need for treatment in alleviating education-related difficulties, instead of a continuous intake for everyday life ADHD-related impairment.
Finally, the authors surprisingly used the wording of the French National Agency for Drug Safety (ANSM) for the prescription of methylphenidate in adults without referencing and without weighing them against data from the international literature. In contrast with most other European countries, the ANSM does not approve the use of methylphenidate in adults, except for narcolepsy and in the particular case of previous effective treatment for ADHD during childhood (for the extended release formulation Concerta®). Even if long-term effects of methylphenidate are still debated as in children, there are evidence for both symptoms reduction and functional improving in adults 5.
The denial of access to a pharmacological treatment in patients newly diagnosed in adulthood can effectively impose an additional penalty. Not only they did not benefit from appropriate care during childhood and moreover, once they are finally diagnosed, patients with severe symptoms and functional impairment cannot access to optimal treatment.
We do believe that fundamental issues in ADHD are to promote access to care for adult patients and decrease stigmatization. The situation in some European countries, and in particular France, from which these data are derived, deserves to evolve.
There are no competing interests to declare.