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Relationship building key to building community on campus and beyond.
Of the many participants of the Queers and Peers Mentorship (QPM) program, the hesitant ones are who Andy King (they/them) tends to appreciate most.
Don’t get them wrong. King has been pleased to see staff members from across NAIT sign up to learn from colleagues about the 2SLGBTQIA+ community at large, and help ensure safe spaces for everyone at the polytechnic to learn and work. But a different kind of success comes when people are willing to shift their perspectives.
“Those folks asked some pretty challenging questions,” says King, customer success team lead with Corporate and Continuing Education who has matched up participants over the years and served as a mentor. In the end, “we got to some common ground, which was really cool.”
Since its inception in 2021 as the only program of its kind in Edmonton, QPM has worked to build community at NAIT by increasing awareness, knowledge and inclusivity. For its efforts, it was recognized in a case study by Toronto-based Pride at Work Canada, an organization dedicated to improving workplace diversity based on gender expression, gender identity and sexual orientation.
“Historically, the workplace has been a challenging environment for 2SLGBTQIA+ individuals,” reads the report. “The QPM program seeks to challenge this status quo by creating a platform for meaningful dialogue and understanding.”
Here, King (who co-chairs the program with NAIT colleague Linden Couteret) explains how that status quo may be changed for the better by co-workers meeting for conversations over coffee.
QPM has been led by staff from the start, thanks to past NAIT employee Jamie Thiessen ( Human Resources ’20). Thiessen spun the program out of a “human library” project that had run during the previous Pride Month, says King. “It was really born of the desire to continue those relationships and develop deeper ones.”
About 40 mentees enrolled in that first year.
“It’s pretty casual and hands off,” says King. Mentors and mentees meet at least once a month, however they choose. “We’re trying to encourage people to develop the relationship rather than focus on any specific goals.”
Additionally, the program hosts events during NAIT’s Pride Week each March.
King emphasizes that QPM is confidential; its success depends on participants being vulnerable but not unsafe.
While the focus is not to achieve goals, there are goals. As described in the case study, ideally mentees will come away with a greater understanding of issues faced by the 2SLGBTQIA+ community, willingness to support, interest in culitvating more welcoming working environments, and more.
Underpinning all of that, King emphasizes, is relationship building. In some cases, they’ve found that a mentee has become a friend, changing the nature of their conversations.
“We didn't really talk about queer stuff that much at the end of the day,” says King.
While it’s casual and conversational, QPM involves work in the form of emotional labour.
“We're asking for a lot of vulnerability,” says King.
That applies to both mentees and mentors.
Often, mentees worry about saying the wrong thing (and, probably, they will). But that’s part of the process, says King. “A big part of [QPM] is putting yourself in the discomfort and figuring out how to navigate that.”
“We're asking for a lot of vulnerability."
Mentors may have to find their way as well. Tough or awkward questions (or both) can arise from mentees’ efforts to learn.
Nevertheless, says King, “it's a much more pleasant context to be asked questions that I'm asked a lot of time anyways.” What’s more, they can coach mentees into asking their questions as respectfully as possible – and to steer them away from no-go topics, says King, who identifies as non-binary.
“People will get really curious about medical things and stuff like that. That really isn’t anybody else's business.”
Mentees report a variety of benefits, from enjoying a safe space, to ask their questions to greater awareness of the impact of their biases, to developing friendships that will continue to deepen their understanding of the 2SLGBTQIA+ community.
But mentors benefit, too, and for reasons beyond the support that may come of QPM, says King.
The program “[gives] queer folks opportunities to be leaders. That's really important, because those opportunities are sometimes limited.” (As reported by Pride at Work Canada, “After decades of work on diversity, equity, and inclusion in the workplace, 2SLGBTQIA+ communities are still largely underrepresented at leadership levels in corporate Canada. … Pathways to leadership … are often unclear, barriered, or nonexistent.”)
The other benefit, King adds, is hope in the face of the current state of 2SLGBTQIA+ inclusion, safety and well-being, which show continued signs of being compromised. King looks forward to once again seeing perspectives broaden and shift with the next QPM intake in fall 2024.
“That it is so focused on relationships, vulnerability and human connection, there's so much worth in that,” they say. “There's so much opportunity to be angry about stuff right now, and I'm just tired of that.
“This feels much better.”
Case study by Pride at Work Canada highlights origins, goals and impact
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ADHD indicates attention-deficit/hyperactivity disorder; CVD, cardiovascular disease.
a Controls were derived from the same base cohort as the cases; thus, a case with a later date of CVD diagnosis could potentially serve as a control for another case in the study.
Crude odds ratios (ORs) were based on cases and controls matched on age, sex, and calendar time. Adjusted ORs (AORs) were based on cases and controls matched on age, sex, and calendar time and adjusted for country of birth, educational level, somatic comorbidities (type 2 diabetes, obesity, dyslipidemia, and sleep disorders), and psychiatric comorbidities (anxiety disorders, autism spectrum disorder, bipolar disorder, conduct disorder, depressive disorder, eating disorders, intellectual disability, personality disorders, schizophrenia, and substance use disorders).
The solid lines represent the adjusted odds ratios, and the shaded areas represent the 95% CIs. In restricted cubic splines analysis, knots were placed at the 10th, 50th, and 90th percentiles of ADHD medication use.
eTable 1. International Classification of Diseases (ICD) Codes from the Swedish National Inpatient Register
eTable 2. Type of Cardiovascular Disease in Cases
eTable 3. Risk of CVD Associated With ADHD Medication Use Across Different Average Defined Daily Doses
eTable 4. Risk of CVD Associated With Cumulative Duration of Use of Different Types of ADHD Medications
eTable 5. Sensitivity Analyses of CVD Risk Associated With Cumulative Use of ADHD Medications, Based On Different Cohort, Exposure, and Outcome Definitions
eFigure. Risk of CVD Associated With Cumulative Use of ADHD Medications, Stratified by Sex
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Zhang L , Li L , Andell P, et al. Attention-Deficit/Hyperactivity Disorder Medications and Long-Term Risk of Cardiovascular Diseases. JAMA Psychiatry. 2024;81(2):178–187. doi:10.1001/jamapsychiatry.2023.4294
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Question Is long-term use of attention-deficit/hyperactivity disorder (ADHD) medication associated with an increased risk of cardiovascular disease (CVD)?
Findings In this case-control study of 278 027 individuals in Sweden aged 6 to 64 years who had an incident ADHD diagnosis or ADHD medication dispensation, longer cumulative duration of ADHD medication use was associated with an increased risk of CVD, particularly hypertension and arterial disease, compared with nonuse.
Meaning Findings of this study suggest that long-term exposure to ADHD medications was associated with an increased risk of CVD; therefore, the potential risks and benefits of long-term ADHD medication use should be carefully weighed.
Importance Use of attention-deficit/hyperactivity disorder (ADHD) medications has increased substantially over the past decades. However, the potential risk of cardiovascular disease (CVD) associated with long-term ADHD medication use remains unclear.
Objective To assess the association between long-term use of ADHD medication and the risk of CVD.
Design, Setting, and Participants This case-control study included individuals in Sweden aged 6 to 64 years who received an incident diagnosis of ADHD or ADHD medication dispensation between January 1, 2007, and December 31, 2020. Data on ADHD and CVD diagnoses and ADHD medication dispensation were obtained from the Swedish National Inpatient Register and the Swedish Prescribed Drug Register, respectively. Cases included individuals with ADHD and an incident CVD diagnosis (ischemic heart diseases, cerebrovascular diseases, hypertension, heart failure, arrhythmias, thromboembolic disease, arterial disease, and other forms of heart disease). Incidence density sampling was used to match cases with up to 5 controls without CVD based on age, sex, and calendar time. Cases and controls had the same duration of follow-up.
Exposure Cumulative duration of ADHD medication use up to 14 years.
Main Outcomes and Measures The primary outcome was incident CVD. The association between CVD and cumulative duration of ADHD medication use was measured using adjusted odds ratios (AORs) with 95% CIs.
Results Of 278 027 individuals with ADHD aged 6 to 64 years, 10 388 with CVD were identified (median [IQR] age, 34.6 [20.0-45.7] years; 6154 males [59.2%]) and matched with 51 672 control participants without CVD (median [IQR] age, 34.6 [19.8-45.6] years; 30 601 males [59.2%]). Median (IQR) follow-up time in both groups was 4.1 (1.9-6.8) years. Longer cumulative duration of ADHD medication use was associated with an increased risk of CVD compared with nonuse (0 to ≤1 year: AOR, 0.99 [95% CI, 0.93-1.06]; 1 to ≤2 years: AOR, 1.09 [95% CI, 1.01-1.18]; 2 to ≤3 years: AOR, 1.15 [95% CI, 1.05-1.25]; 3 to ≤5 years: AOR, 1.27 [95% CI, 1.17-1.39]; and >5 years: AOR, 1.23 [95% CI, 1.12-1.36]). Longer cumulative ADHD medication use was associated with an increased risk of hypertension (eg, 3 to ≤5 years: AOR, 1.72 [95% CI, 1.51-1.97] and >5 years: AOR, 1.80 [95% CI, 1.55-2.08]) and arterial disease (eg, 3 to ≤5 years: AOR, 1.65 [95% CI, 1.11-2.45] and >5 years: AOR, 1.49 [95% CI, 0.96-2.32]). Across the 14-year follow-up, each 1-year increase of ADHD medication use was associated with a 4% increased risk of CVD (AOR, 1.04 [95% CI, 1.03-1.05]), with a larger increase in risk in the first 3 years of cumulative use (AOR, 1.08 [95% CI, 1.04-1.11]) and stable risk over the remaining follow-up. Similar patterns were observed in children and youth (aged <25 years) and adults (aged ≥25 years).
Conclusions and Relevance This case-control study found that long-term exposure to ADHD medications was associated with an increased risk of CVDs, especially hypertension and arterial disease. These findings highlight the importance of carefully weighing potential benefits and risks when making treatment decisions about long-term ADHD medication use. Clinicians should regularly and consistently monitor cardiovascular signs and symptoms throughout the course of treatment.
Attention-deficit/hyperactivity disorder (ADHD) is a common psychiatric disorder characterized by developmentally inappropriate inattentiveness, impulsivity, and hyperactivity. 1 , 2 Pharmacological therapy, including both stimulants and nonstimulants, is recommended as the first-line treatment for ADHD in many countries. 1 , 3 The use of ADHD medication has increased greatly in both children and adults during the past decades. 4 Although the effectiveness of ADHD medications has been demonstrated in randomized clinical trials (RCTs) and other studies, 5 , 6 concerns remain regarding their potential cardiovascular safety. 7 Meta-analyses of RCTs have reported increases in heart rate and blood pressure associated with both stimulant and nonstimulant ADHD medications. 5 , 7 - 9
As RCTs typically evaluate short-term effects (average treatment duration of 75 days), 7 it remains uncertain whether and to what extent the increases in blood pressure and heart rate associated with ADHD medication lead to clinically significant cardiovascular disease (CVD) over time. Longitudinal observational studies 10 - 12 examining the association between ADHD medication use and serious cardiovascular outcomes have emerged in recent years, but the findings have been mixed. A meta-analysis 13 of observational studies found no statistically significant association between ADHD medication and risk of CVD. However, the possibility of a modest risk increase cannot be ruled out due to several methodological limitations in these studies, including confounding by indication, immortal time bias, and prevalent user bias. Additionally, most of these studies had an average follow-up time of no more than 2 years. 13 , 14 Thus, evidence regarding the long-term cardiovascular risk of ADHD medication use is still lacking.
Examining the long-term cardiovascular risk associated with ADHD medicine use is clinically important given that individuals with a diagnosis of ADHD, regardless of whether they receive treatment, face an elevated risk of CVD. 15 Additionally, a substantial proportion of young individuals with ADHD continues to have impairing symptoms in adulthood, 16 necessitating prolonged use of ADHD medication. Notably, studies have indicated a rising trend in the long-term use of ADHD medications, with approximately half of individuals using ADHD medication for over 5 years. 17 Furthermore, evidence is lacking regarding how cardiovascular risk may vary based on factors such as type of CVD, type of ADHD medication, age, and sex. 13 Therefore, there is a need for long-term follow-up studies to address these knowledge gaps and provide a more comprehensive understanding of the cardiovascular risks associated with ADHD medication use. This information is also crucial from a public health perspective, particularly due to the increasing number of individuals receiving ADHD medications worldwide. 4
This study aimed to assess the association between cumulative use of ADHD medication up to 14 years and the risk of CVD by using nationwide health registers in Sweden. We hypothesized that longer cumulative use of ADHD medication would be associated with increased CVD risk. In addition, we aimed to examine whether the associations differ across types of ADHD medication, types of CVD, sex, and age groups.
We used data from several Swedish nationwide registers linked through unique personal identification numbers. 18 Diagnoses were obtained from the National Inpatient Register, 19 which contains data on inpatient diagnoses since 1973 and outpatient diagnoses since 2001. Information on prescribed medications was retrieved from the Swedish Prescribed Drug Register, which contains all dispensed medications in Sweden since July 2005 and includes information on drug identity based on the Anatomical Therapeutic Chemical (ATC) classification, 20 dispensing dates, and free-text medication prescriptions. Socioeconomic factors were obtained from the Longitudinal Integrated Database for Health Insurance and Labour Market studies. 21 Information on death was retrieved from the Swedish Cause of Death Register, 22 which contains information on all deaths since 1952. The study was approved by the Swedish Ethical Review Authority. Informed patient consent is not required for register-based studies in Sweden. The study followed the Reporting of Studies Conducted Using Observational Routinely Collected Health Data–Pharmacoepidemiological Research ( RECORD-PE ) guideline. 23
We conducted a nested case-control study of all individuals residing in Sweden aged 6 to 64 years who received an incident diagnosis of ADHD or ADHD medication dispensation 15 between January 1, 2007, and December 31, 2020. The diagnosis of ADHD ( International Statistical Classification of Diseases and Related Health Problems, Tenth Revision [ ICD-10 ] code F90) was identified from the National Inpatient Register. Incident ADHD medication dispensation was identified from the Swedish Prescribed Drug Register and was defined as a dispensation after at least 18 months without any ADHD medication dispensation. 24 Baseline (ie, cohort entry) was defined as the date of incident ADHD diagnosis or ADHD medication dispensation, whichever came first. Individuals with ADHD medication prescriptions for indications other than ADHD 25 and individuals who emigrated, died, or had a history of CVD before baseline were excluded from the study. The cohort was followed until the case index date (ie, the date of CVD diagnosis), death, migration, or the study end date (December 31, 2020), whichever came first.
Within the study cohort, we identified cases as individuals with an incident diagnosis of any CVD (including ischemic heart diseases, cerebrovascular diseases, hypertension, heart failure, arrhythmias, thromboembolic disease, arterial disease, and other forms of heart disease; eTable 1 in Supplement 1 ) during follow-up. For each case, the date of their CVD diagnosis was assigned as the index date. Using incidence density sampling, 26 up to 5 controls without CVD were randomly selected for each case from the base cohort of individuals with ADHD. The matching criteria included age, sex, and calendar time, ensuring that cases and controls had the same duration of follow-up from baseline to index date. Controls were eligible for inclusion if they were alive, living in Sweden, and free of CVD at the time when their matched case received a diagnosis of CVD, with the index date set as the date of CVD diagnosis of the matched case ( Figure 1 ). Controls were derived from the same base cohort as the cases. Thus, a case with a later date of CVD diagnosis could potentially serve as a control for another case in the study. 26
The main exposure was cumulative duration of ADHD medication use, which included all ADHD medications approved in Sweden during the study period, including stimulants (methylphenidate [ATC code N06BA04], amphetamine [ATC code N06BA01], dexamphetamine [ATC code N06BA02], and lisdexamfetamine [ATC code N06BA12]) as well as nonstimulants (atomoxetine [ATC code N06BA09] and guanfacine [ATC code C02AC02]). Duration of ADHD medication use was derived from a validated algorithm that estimates treatment duration from free text in prescription records. 25 The cumulative duration of ADHD medication use was calculated by summing all days covered by ADHD medication between baseline and 3 months prior to the index date. The last 3 months before the index date were excluded to reduce reverse causation, as clinicians’ perception of potential cardiovascular risks may influence ADHD medication prescription. This time window was chosen because routine psychiatric practice in Sweden limits a prescription to a maximum 3 months at a time. 27 Individuals with follow-up of less than 3 months were excluded.
We conducted conditional logistic regression analyses to estimate odds ratios (ORs) for the associations between cumulative durations of ADHD medication use and incident CVD. Crude ORs were adjusted for all matching variables (age, sex, and calendar time) by design. Adjusted ORs (AORs) were additionally controlled for country of birth (Sweden vs other), highest educational level (primary or lower secondary, upper secondary, postsecondary or postgraduate, or unknown; individuals aged <16 years were included as a separate category), and diagnoses of somatic (type 2 diabetes, obesity, dyslipidemia, and sleep disorders) and psychiatric comorbidities (anxiety disorders, autism spectrum disorder, bipolar disorder, conduct disorder, depressive disorder, eating disorders, intellectual disability, personality disorders, schizophrenia, and substance use disorders; eTable 1 in Supplement 1 ) before baseline. The association between cumulative ADHD medication use and incident CVD was assessed using both continuous and categorical measures (no ADHD medication use, 0 to ≤1, 1 to ≤2, 2 to ≤3, 3 to ≤5, and >5 years). To capture potential nonlinear associations, we used restricted cubic splines to examine ADHD medication use as a continuous measure throughout follow-up. 28 The associations were examined in the full sample and stratified by age at baseline, that is, children or youth (<25 years old) and adults (≥25 years old). Furthermore, to evaluate the association with dosage of ADHD medication, we estimated the risk of CVD associated with each 1-year increase in use of ADHD medication across different dosage groups categorized by the average defined daily dose (DDD; for instance, 1 DDD of methylphenidate equals 30 mg) during follow-up. 29
In subgroup analyses, we examined the associations between ADHD medication use and specific CVDs, including arrhythmias, arterial disease, cerebrovascular disease, heart failure, hypertension, ischemic heart disease, and thromboembolic disease (eTable 1 in Supplement 1 ). Additionally, we investigated the associations with CVD risk for the most commonly prescribed ADHD medications in Sweden, ie, methylphenidate, lisdexamfetamine, and atomoxetine, while adjusting for other ADHD medication use. We also examined sex-specific associations.
To further examine the robustness of our findings, we conducted 4 sensitivity analyses. First, we restricted the sample to ever users of ADHD medication to reduce unmeasured confounding between ADHD medication users and nonusers. Second, we assessed ADHD medication exposure over the entire follow-up period without excluding the 3 months prior to the index date. Third, to capture fatal cardiovascular events, we additionally included death by CVD in the outcome definition. Finally, we constructed a conditional logistic regression model that adjusted for propensity scores of ADHD medication use. Data management was performed using SAS, version 9.4 (SAS Institute Inc) and all analyses were performed using R, version 4.2.3 (R Foundation for Statistical Computing).
The study cohort consisted of 278 027 individuals with ADHD aged 6 to 64 years. The incidence rate of CVD was 7.34 per 1000 person-years. After applying exclusion criteria and matching, the analysis included 10 388 cases (median [IQR] age at baseline, 34.6 (20.0-45.7) years; 6154 males [59.2%] and 4234 females [40.8%]) and 51 672 matched controls (median [IQR] age at baseline, 34.6 [19.8-45.6] years; 30 601 males [59.2%] and 21 071 females [40.8%]) ( Figure 1 and Table 1 ). Median (IQR) follow-up in both groups was 4.1 (1.9-6.8) years. Among the controls, 3363 had received a CVD diagnosis after their index dates. The most common types of CVD in cases were hypertension (4210 cases [40.5%]) and arrhythmias (1310 cases [12.6%]; eTable 2 in Supplement 1 ). Table 1 presents the sociodemographic information and somatic and psychiatric comorbidities in cases and controls. In general, cases had higher rates of somatic and psychiatric comorbidities and a lower level of educational attainment compared with controls.
A similar proportion of cases (83.9%) and controls (83.5%) used ADHD medication during follow-up, with methylphenidate being the most commonly dispensed type, followed by atomoxetine and lisdexamfetamine. Longer cumulative duration of ADHD medication use was associated with an increased risk of CVD compared with nonuse (0 to ≤1 year: AOR, 0.99 [95% CI, 0.93-1.06]; 1 to ≤2 years: AOR, 1.09 [95% CI, 1.01-1.18]; 2 to ≤3 years: AOR, 1.15 [95% CI, 1.05-1.25]; 3 to ≤5 years: AOR, 1.27 [95% CI, 1.17-1.39]; and >5 years: AOR, 1.23 [95% CI, 1.12-1.36]) ( Figure 2 ). The restricted cubic spline model suggested a nonlinear association, with the AORs increasing rapidly for the first 3 cumulative years of ADHD medication use and then becoming stable thereafter ( Figure 3 ). Throughout the entire follow-up, each 1-year increase in the use of ADHD medication was associated with a 4% increased risk of CVD (AOR, 1.04 [95% CI, 1.03-1.05]), and the corresponding increase for the first 3 years was 8% (AOR, 1.08 [95% CI, 1.04-1.11]). We observed similar results when examining children or youth and adults separately ( Figure 2 ). The restricted cubic spline model suggested a similar nonlinear association, with higher AORs in children or youth than in adults, but the 95% CIs largely overlapped ( Figure 3 ). Furthermore, similar associations were observed for females and males (eFigure in Supplement 1 ). The dosage analysis showed that the risk of CVD associated with each 1 year of ADHD medication use increased with higher average DDDs. The risk was found to be statistically significant only among individuals with a mean dose of at least 1.5 times the DDD (eTable 3 in Supplement 1 ). For example, among individuals with a mean DDD of 1.5 to 2 or less (eg, for methylphenidate, 45 to ≤60 mg), each 1-year increase in ADHD medication use was associated with a 4% increased risk of CVD (AOR, 1.04 [95% CI, 1.02-1.05]). Among individuals with a mean DDD >2 (eg, for methylphenidate >60 mg), each 1-year increase in ADHD medication use was associated with 5% increased risk of CVD (AOR, 1.05 [95% CI, 1.03-1.06]).
When examining the risk for specific CVDs, we found that long-term use of ADHD medication (compared with no use) was associated with an increased risk of hypertension (AOR, 1.72 [95% CI, 1.51-1.97] for 3 to ≤5 years; AOR, 1.80 [95% CI 1.55-2.08] for >5 years) ( Table 2 ), as well as arterial disease (AOR, 1.65 [95% CI, 1.11-2.45] for 3 to ≤5 years; AOR, 1.49 [95% CI 0.96-2.32] for >5 years). However, we did not observe any statistically significant increased risk for arrhythmias, heart failure, ischemic heart disease, thromboembolic disease, or cerebrovascular disease ( Table 2 ). Furthermore, long-term use of methylphenidate (compared with no use) was associated with an increased risk of CVD (AOR, 1.20 [95% CI, 1.10-1.31] for 3 to ≤5 years; AOR, 1.19 [95% CI, 1.08-1.31]) for >5 years; eTable 4 in Supplement 1 ). Compared with no use, lisdexamfetamine was also associated with an elevated risk of CVD (AOR, 1.23 [95% CI, 1.05-1.44] for 2 to ≤3 years; AOR, 1.17 [95% CI, 0.98-1.40] for >3 years), while the AOR for atomoxetine use was significant only for the first year of use (1.07 [95% CI 1.01-1.13]; eTable 4 in Supplement 1 ).
In sensitivity analyses, we observed a similar pattern of estimates when the analysis was restricted to ever users of ADHD medications. Significantly increased risk of CVD was found when comparing ADHD medication use for 1 year or less with use for 3 to 5 or less years (AOR, 1.28 (95% CI, 1.18-1.38) or for use for more than 5 years (AOR, 1.24 [95% CI, 1.13-1.36]) (eTable 5 in Supplement 1 ). When assessing ADHD medication use across the entire follow-up period, and compared with no use, the pattern of estimates was similar to the main analysis (3 to ≤5 years: AOR, 1.28 [95% CI, 1.18-1.39]; >5 years: AOR, 1.25 [95% CI, 1.14-1.37]) (eTable 5 in Supplement 1 ). The analysis that included cardiovascular death as a combined outcome also had results similar to the main analysis. Moreover, when adjusting for propensity scores of ADHD medication use, the findings remained consistent (eTable 5 in Supplement 1 ).
This large, nested case-control study found an increased risk of incident CVD associated with long-term ADHD medication use, and the risk increased with increasing duration of ADHD medication use. This association was statistically significant both for children and youth and for adults, as well as for females and males. The primary contributors to the association between long-term ADHD medication use and CVD risk was an increased risk of hypertension and arterial disease. Increased risk was also associated with stimulant medication use.
We found individuals with long-term ADHD medication use had an increased risk of incident CVD in a dose-response manner in the first 3 years of cumulative ADHD medication use. To our knowledge, few previous studies have investigated the association between long-term ADHD medication use and the risk of CVD with follow-up of more than 2 years. 13 The only 2 prior studies with long-term follow-up (median, 9.5 and 7.9 years 30 , 31 ) found an average 2-fold and 3-fold increased risk of CVD with ADHD medication use compared with nonuse during the study period, yet 1 of the studies 30 included only children, and participants in the other study 31 were not the general population of individuals with ADHD (including those with ADHD and long QT syndrome). Furthermore, both studies were subject to prevalent user bias. Results from the current study suggest that the CVD risk associated with ADHD medication use (23% increased risk for >5 years of ADHD medication use compared with nonuse) is lower than previously reported. 30 , 31 Furthermore, we observed that the increased risk stabilized after the first several years of medication use and persisted throughout the 14-year follow-up period.
The association between ADHD medication use and CVD was significant for hypertension and arterial disease, while no significant association was observed with other types of cardiovascular events. To our knowledge, only 1 previous study 12 has examined the association between ADHD medication use and clinically diagnosed hypertension, and it found an increased risk, although the increase was not statistically significant. Furthermore, increased blood pressure associated with ADHD medication use has been well documented. 7 , 9 One study 32 found that blood pressure was mainly elevated during the daytime, suggesting that the cardiovascular system may recover at night. However, the cross-sectional nature of that study cannot preclude a long-term risk of clinically diagnosed hypertension associated with ADHD medication use. We also identified an increased risk for arterial disease. To date, no previous study has explored the association between ADHD medication use and arterial disease. A few studies have reported that ADHD medication may be associated with changes in serum lipid profiles, but the results were not consistent. 33 , 34 Further research is needed on the potential implications of ADHD medications for individuals’ lipid profiles. We did not observe any association between ADHD medication use and the risk of arrhythmias. A recent systematic review of observational studies of ADHD medication use reported an elevated risk of arrhythmias, but the finding was not statistically significant. 13 A review of RCTs also found that the use of stimulants was associated with an average increase in heart rate of 5.7 beats/min, 9 but no evidence of prolonged QT interval or tachycardia was found based on electrocardiograms. 7 Additionally, it is worth noting that some individuals receiving ADHD medications might be prescribed antiarrhythmic β-blockers to alleviate palpitation symptoms, thus potentially attenuating an association between ADHD medications and arrhythmias. Nevertheless, the absence of an association between ADHD medication use and clinically diagnosed arrhythmias in the present study does not rule out an increased risk for mild arrhythmias or subclinical symptoms, as palpitations and sinus tachycardia are not routinely coded as arrhythmia diagnoses. Further research is necessary to replicate our findings.
Regarding types of ADHD medication, findings of the present study suggest that increasing cumulative durations of methylphenidate and lisdexamfetamine use were associated with incident CVD, while the associations for atomoxetine were statistically significant only for the first year of use. Previous RCTs have reported increased blood pressure and heart rate with methylphenidate, lisdexamfetamine, and atomoxetine, 5 , 35 , 36 but the mechanisms behind these adverse effects are still a topic of debate; there might be differences in cardiovascular adverse effects in stimulants vs nonstimulants. 37
We found that the association between cumulative duration of ADHD medication use and CVD was similar in females and males. Previous investigations exploring sex-specific association found higher point estimates in females, although the differences were not statistically significant. 13 Research has indicated that females diagnosed with ADHD may demonstrate different comorbidity patterns and potentially have different responses to stimulant medications compared with males. 38 - 40 Therefore, additional studies are needed to explore and better understand the potential sex-specific differences in cardiovascular responses to ADHD medications.
A strength of this study is that data on ADHD medication prescriptions and CVD diagnoses were recorded prospectively, so the results were not affected by recall bias. The findings should, however, be interpreted in the context of several limitations. First, our approach for identification of patients with CVD was based on recorded diagnoses and there could be under ascertainment of cardiovascular diagnoses in the registers used. This means that some controls may have had undiagnosed CVD that did not yet require medical care, which would tend to underestimate associations between ADHD medication use and CVD. Second, exposure misclassification may have occurred if patients did not take their medication as prescribed. This misclassification, if nondifferential, would tend to reduce ORs such that the estimates we observed were conservative. Third, while we accounted for a wide range of potential confounding variables, considering the observational nature of the study and the possibility of residual confounding, we could not prove causality. It is possible that the association observed might have been affected by time-varying confounders. For example, other psychotropic medications and lifestyle factors could have affected both ADHD medication use and the occurrence of cardiovascular events. 41 , 42 Confounding by ADHD severity is also a potential factor to consider, as individuals with more severe ADHD symptoms may have more comorbidities and a less healthy lifestyle, which could affect the risk of CVD. Fourth, the study did not examine the risk of CVD among individuals with preexisting CVD. Individuals with preexisting CVD represent a distinct clinical group that requires careful monitoring; thus, evaluating the risk among them necessitates a different study design that carefully considers the potential impact of prior knowledge and periodic monitoring. Finally, the results by type of ADHD medication and type of CVD need to be replicated by studies with larger sample sizes.
The results of this population-based case-control study with a longitudinal follow-up of 14 years suggested that long-term use of ADHD medication was associated with an increased risk of CVD, especially hypertension and arterial disease, and the risk was higher for stimulant medications. These findings highlight the importance of carefully weighing potential benefits and risks when making treatment decisions on long-term ADHD medication use. Clinicians should be vigilant in monitoring patients, particularly among those receiving higher doses, and consistently assess signs and symptoms of CVD throughout the course of treatment. Monitoring becomes even more crucial considering the increasing number of individuals engaging in long-term use of ADHD medication.
Accepted for Publication: August 29, 2023.
Published Online: November 22, 2023. doi:10.1001/jamapsychiatry.2023.4294
Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2023 Zhang L et al. JAMA Psychiatry .
Corresponding Authors: Zheng Chang, PhD ( [email protected] ) and Le Zhang, PhD ( [email protected] ), Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobels väg 12A, 171 65 Stockholm, Sweden.
Author Contributions: Dr Zhang and Prof Chang had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Zhang, Johnell, Larsson, Chang.
Acquisition, analysis, or interpretation of data: Zhang, Li, Andell, Garcia-Argibay, Quinn, D'Onofrio, Brikell, Kuja-Halkola, Lichtenstein, Johnell, Chang.
Drafting of the manuscript: Zhang.
Critical review of the manuscript for important intellectual content: All authors.
Statistical analysis: Zhang, Li.
Obtained funding: Larsson, Chang.
Administrative, technical, or material support: Garcia-Argibay, D'Onofrio, Kuja-Halkola, Lichtenstein, Chang.
Supervision: Andell, Lichtenstein, Johnell, Larsson, Chang.
Conflict of Interest Disclosures: Dr Larsson reported receiving grants from Takeda Pharmaceuticals and personal fees from Takeda Pharmaceuticals, Evolan, and Medici Medical Ltd outside the submitted work. No other disclosures were reported.
Funding/Support: This study was supported by grants from the Swedish Research Council for Health, Working Life, and Welfare (2019-01172 and 2022-01111) (Dr Chang) and the European Union’s Horizon 2020 research and innovation program under grant agreement 965381 (Dr Larsson).
Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Data Sharing Statement: See Supplement 2 .
Published in sept 2022.
What you need to know, click the key points below for more information on the topic, there are likely over a billion pets worldwide.
Families in the U.S., Brazil, EU and China alone account for over half a billion dogs and cats, while more than half the world is estimated to have a pet at home.
particularly in millennial households, which tend to be smaller families and have children later in life.
in emerging markets.
for people including better heart health, lower levels of depression and anxiety, and more.
The ownership of cats and dogs has been steadily increasing across the globe, including in emerging economies..
Sources 1 https://europeanpetfood.org/about/statistics/ , 2 https://www.prnewswire.com/news-releases/frost–sullivan-chinese-pet-owners-spend-an-average-of-rmb3-969-per-year-300823597.html , 3 https://www.avma.org/blog/pet-populations-are-way
Sources 4 https://www.avma.org/blog/pet-populations-are-way , 5 https://www.prnewswire.com/news-releases/frost–sullivan-chinese-pet-owners-spend-an-average-of-rmb3-969-per-year-300823597.html , 6 https://www.zzf.de/presse/meldungen/meldungen/article/trend-zum-heimtier-haelt-auch-2020-an.html , 7 http://abinpet.org.br/infos_gerais/ , 8 https://enelveterinario.com/wp-content/uploads/2018/11/Informe-sectorial-2017.pdf , 9 https://www.facco.fr/population-animale/ , 10 https://europeanpetfood.org/about/statistics/ , 11 https://www.flandersinvestmentandtrade.com/export/sites/trade/files/market_studies/Pet%20food%20market%20Thailand.pdf , 12 https://animalmedicinesaustralia.org.au/wp-content/uploads/2021/08/AMAU005-PATP-Report21_v1.41_WEB.pdf , 13 https://www.pfma.org.uk/statistics , 14 https://www.kodami.it/rapporto-assalco-zoomark-2020-un-animale-in-ogni-famiglia-italiana/ , 15 https://www.senado.gob.mx/64/gaceta_del_senado/documento/86584 , 16 https://cahi-icsa.ca/news/2020-canadian-pet-population-figures-released , 17 https://apps.fas.usda.gov/newgainapi/api/Report/DownloadReportByFileName?fileName=Pet%20Food%20Market%20in%20Japan_Osaka%20ATO_Japan_01-31-2021 , 18 https://europeanpetfood.org/about/statistics/ , 19 https://europeanpetfood.org/about/statistics / , 20 https://www.iiptf.in/petbusiness/whyindia.html , 21 http://www.scielo.org.za/pdf/jsava/v91n1/06.pdf
Billions of households around the world are unified by a common theme – pet ownership. Sharing your home with a pet is a common language that cuts across country and culture.
More than half of the global population is estimated to have a pet at home. 22 https://www.gfk.com/insights/mans-best-friend-global-pet-ownership-and-feeding-trends
Families in the U.S., EU and China alone have over half a billion dogs and cats.
In the U.S., 70 percent of households owned a pet as of 2021 compared to 68 percent in 2016. 23 https://www.americanpetproducts.org/press_releasedetail.asp?id=1242 https://www.mceldrewyoung.com/wp-content/uploads/2018/08/2017-2018-Pet-Survey.pdf
Globally, dogs are the most popular pet, present in around one in three homes. Almost a quarter of pet owners have a cat. 24 https://www.gfk.com/insights/mans-best-friend-global-pet-ownership-and-feeding-trends
The evidence is clear – pet populations worldwide are rising and there is little indication it will slow down anytime soon., why is pet ownership on the rise.
Demographic changes, rising income levels and the Covid-19 pandemic have driven more people to adopt pets.
Read our ‘ Impact of Covid-19 ‘ case study to see how the pandemic has increased pet ownership levels in Australia.
“There has been a huge change in the culture of pet ownership, and this will also occur in emerging markets – South-East / South Asia, Central Asia, Sub-Saharan Africa, Eastern Europe.” Dr Shane Ryan, Veterinarian and Past President, World Small Animal Veterinary Association
Growth is most evident in those countries which are witnessing the expansion of the “middle class”, which is also contributing to shifting attitudes and the emergence of a new “pet culture” based around the increased humanization of pets and increased number of pets kept for companionship alone.
In China, a relaxation of pet ownership regulations and a falling birth rate are additional contributors to an increase in pet ownership. Pet ownership increased 113% between 2014 and 2019, and by 2024, experts estimate China will have the most pets in the world. 25 https://www.bloomberg.com/news/articles/2019-12-04/china-spends-29-billion-on-pampering-pets-as-birthrate-slows Elsewhere in Asia, pet ownership in South Korea grew from 5 million to 7.5 million between 2014 and 2018, representing 50% growth. 26 https://www.petfairasia.com/en/asia-markets/south-korea-pet-market/
“Pet ownership has a lot to do with disposable income. Because of that, fast-advancing countries, like the Asian countries, but also Eastern Europe will certainly see further increase of pet ownership.” Dr. Wolfgang Dohne, Veterinarian and Senior Vice President, Federation of European Companion Animal Veterinary Associations
Trends in pet ownership are closely linked to global demographic changes.
Early analysis also shows that Gen Z, despite their young age, represents a growing segment of pet owners (14% in the U.S.) and may accelerate the ‘pet boom.’ 27 https://www.americanpetproducts.org/press_releasedetail.asp?id=1242
In the United States, millennials now account for a third of all pet owners.
“The really emerging demographic is the millennial couple first-time pet owners. Before having a child, they’re going to adopt a pet. That’s the training wheels for them to become parents.” Alex Douzet, CEO, Pumpkin Pet Insurance, U.S.
More people are recognising and enjoying the positive benefits of companion animals but this also brings animal health issues to the fore.
A growing global pet population means an increase in veterinary caseloads. Almost half of practices reported an increase in a 91-country survey.
Pet abandonments are also on the rise. Up to eight million animals enter rescue shelters every year in the U.S., with about half of these eventually euthanized. 28 https://bmcvetres.biomedcentral.com/articles/10.1186/s12917-020-02728-2
However, industry data found that fears of a ‘pet abandonment’ crisis following the pandemic pet boom has not come to fruition. Rehoming levels were actually down in 2021 vs 2019, both in real figures and as a proportion of animal populations. 29 Data from PetPoint https://www.petpoint.com /
Studies have shown time and time again – pet ownership leads to better health outcomes for people. this is the one health power of pets..
Pet ownership provides a range of therapeutic, physiological, psychological, and psychosocial benefits to owners. 30 https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0122085#sec005 These include:
Pet ownership has also been strongly linked with a reduction in healthcare costs in the U.S., contributing to fewer visits to doctors and improved general health. 31 https://habri.org/pressroom/20151214
Studies have also shown that these benefits remain even when adjusted for demographic, socioeconomic factors, education, medication use, etc., 32 https://www.ahajournals.org/doi/10.1161/CIRCOUTCOMES.119.005887 showing that the link between pet ownership and better health is persistent and strong. Healthy pets contribute to our health. That is the ‘One Health’ power of these pets.
“Pets are healthier and well cared for because their status has changed…as we’re more attuned to our own wellness, it translates to those we love around us.” Dr Siraya Chunekamrai, President, World Small Animal Veterinary Association
Researchers attribute the clear link between pet ownership and improved health to: 33 https://www.ahajournals.org/doi/10.1161/CIRCOUTCOMES.119.005887
Increased levels of outdoor physical activity that often accompany pet ownership (e.g. regular dog walking).
The sustained mental health benefits brought on by pet companionship.
Greater exposure to germs that can ‘favourably alter the gut microbiome of an owner’.
This is why the American Heart Association has stated that dog ownership “may have some causal role in reducing cardiovascular disease risk” and “may be reasonable for reduction in cardiovascular disease risk”. 34 https://www.ahajournals.org/doi/10.1161/CIR.0b013e31829201e1
The Covid-19 pandemic has had a significant impact on pet ownership, as shown in recent research by Animal Medicines Australia. There has been a steady rise in pet ownership in the country, with the number of Australian households owning pets having increased from 61 percent in 2019, to 69 percent in 2021. This means the total number of pets in Australia has increased from 28.5 million in 2019 to 30.4 million in 2021.
Millions of Australians decided to adopt a pet during the pandemic, adding more than a million dogs to the total pet population , rising from 5.1 million owned dogs in 2019 to 6.34 million in 2021. The pandemic has been a key motivator for pet ownership, with 19 percent of dogs and 24 percent of all cats owned by Australians acquired since the beginning of the pandemic.
New owners stated that owning a new pet during the pandemic was not a spontaneous decision , however, but that pandemic restrictions had helped to “on-board” a pet that they had previously wanted, such as through greater time spent at home, for instance.
Source: https://animalmedicinesaustralia.org.au/report/pets-and-the-pandemic-a-social-research-snapshot-of-pets-and-people-in-the-covid-19-era-2/
Acknowledgements.
This report is produced by HealthforAnimals, the global animal health association, and was informed by interviews with experts in the pet world. We thank the following people for their participation: Alex Douzet, Dana Brooks, Edival Santos, Lawson Cairns, Leonardo Brandao, Marie-Jose Enders, Siraya Chunkekamrai, Shane Ryan and Wolfgang Dohne. The information in this report focuses on dogs and cats as these are the overwhelming majority of pets, although other animals such as horses, birds and fish can be pets as well.
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Through the case method, you can "try on" roles you may not have considered and feel more prepared to change or advance your career. 5. Build Your Self-Confidence. Finally, learning through the case study method can build your confidence. Each time you assume a business leader's perspective, aim to solve a new challenge, and express and ...
Advantages. 1. In-depth analysis of complex phenomena. Case study design allows researchers to delve deeply into intricate issues and situations. By focusing on a specific instance or event, researchers can uncover nuanced details and layers of understanding that might be missed with other research methods, especially large-scale survey studies.
Researchers, economists, and others frequently use case studies to answer questions across a wide spectrum of disciplines, from analyzing decades of climate data for conservation efforts to developing new theoretical frameworks in psychology. Learn about the different types of case studies, their benefits, and examples of successful case studies.
Beyond teaching specific subject matter, the case study method excels in instilling meta-skills in students. This article explains the importance of seven such skills: preparation, discernment ...
Capturing reality: One of their key benefits is their ability to capture what Hodkinson and Hodkinson call 'lived reality' (2001: 3). As they put it, case studies have the potential, when applied successfully, to 'retain more of the "noise" of real life than many other types of research' (Hodkinson and Hodkinson, 2001: 3).
A case study protocol outlines the procedures and general rules to be followed during the case study. This includes the data collection methods to be used, the sources of data, and the procedures for analysis. Having a detailed case study protocol ensures consistency and reliability in the study.
The purpose of case study research is twofold: (1) to provide descriptive information and (2) to suggest theoretical relevance. Rich description enables an in-depth or sharpened understanding of the case. It is unique given one characteristic: case studies draw from more than one data source. Case studies are inherently multimodal or mixed ...
A case study is one of the most commonly used methodologies of social research. This article attempts to look into the various dimensions of a case study research strategy, the different epistemological strands which determine the particular case study type and approach adopted in the field, discusses the factors which can enhance the effectiveness of a case study research, and the debate ...
Case studies are good for describing, comparing, evaluating and understanding different aspects of a research problem. Table of contents. When to do a case study. Step 1: Select a case. Step 2: Build a theoretical framework. Step 3: Collect your data. Step 4: Describe and analyze the case.
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Case studies can help lawyers, policymakers, and ethical professionals to develop critical thinking skills, analyze complex cases, and make informed decisions. Purpose of Case Study. The purpose of a case study is to provide a detailed analysis of a specific phenomenon, issue, or problem in its real-life context. A case study is a qualitative ...
A case study is a comprehensive report of the results of theory testing or examining emerging themes of a business in real life context. Case studies are also often used in the healthcare industry, conducting health services research with primary research interest around routinely collected healthcare data.
Yin (1994) defines case study as an empirical research activity that, by using versatile empirical material gathered in several different ways, examines a specific present-day event or action in a bounded environment. Case study objective is to do intensive research on a specific case, such as individual, group, institute, or community.
This study further highlights that while establishing the foundations for a successful and enjoyable collaborative research team is essential, the benefits of doing this go beyond the immediacy of the relationships developed and publications achieved.
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The benefits found in these efforts led the approach to transition to other industries, allowing for the examination of results through proposed decisions, processes, or outcomes. ... Generalization does not apply to a larger population group with the case study method. What researchers can do with this information is to suggest a predictable ...
Case studies are one of the best ways to stimulate new research. A case study can be completed, and if the findings are valuable, they can lead to new and advanced research in the field. There has been a great deal of research done that wouldn't have been possible without case studies. An example of this is the sociological study Nickel and Dimed.
Case studies can foster themes for future research. Researchers may use case study conclusions to test hypotheses for further investigation. Additional research, such as this, can lead to valuable ...
Even interviews can be conducted over the phone. That means this method is good for formative research that is exploratory in nature, even if it must be completed from a remote location. 6. It is inexpensive. Compared to other methods of research, the case study method is rather inexpensive.
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The activity was carried out in pairs to promote interdependence, collaboration and creativity. The average length of the case studies was about six pages. The task consisted of four phases: ξ Phase 1. Before starting the activity, students were asked to work on a case study prepared and facilitated by teachers.
Case study is a research methodology, typically seen in social and life sciences. There is no one definition of case study research.1 However, very simply… 'a case study can be defined as an intensive study about a person, a group of people or a unit, which is aimed to generalize over several units'.1 A case study has also been described as an intensive, systematic investigation of a ...
Advantages to the use of case studies in class. A major advantage of teaching with case studies is that the students are actively engaged in figuring out the principles by abstracting from the examples. This develops their skills in: Problem solving. Analytical tools, quantitative and/or qualitative, depending on the case.
Published studies on the benefits of training; ... However, it takes time to build a thorough case — especially alone. Doing so with support from other areas of the business will strengthen the argument for learning while also decentralizing the planning and execution process. This will help while building a case, but also when the case has ...
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This study adopts a case study design to investigate the teacher identity of a novice lecturer of EMI in a Chinese higher education institute, examining the role of emotions in shaping EMI teacher identity. Multiple data sources, including interviews, reflective journals, and digital conversations and posts, were collected from September 2021 ...
What it's supposed to do While the focus is not to achieve goals, there are goals. As described in the case study, ideally mentees will come away with a greater understanding of issues faced by the 2SLGBTQIA+ community, willingness to support, interest in culitvating more welcoming working environments, and more.
Findings In this case-control study of 278 027 individuals in Sweden aged 6 to 64 years who had an incident ADHD diagnosis or ADHD medication dispensation, longer ... These findings highlight the importance of carefully weighing potential benefits and risks when making treatment decisions about long-term ADHD medication use. Clinicians should ...
Case Study - The Impact of Covid-19. The Covid-19 pandemic has had a significant impact on pet ownership, as shown in recent research by Animal Medicines Australia. There has been a steady rise in pet ownership in the country, with the number of Australian households owning pets having increased from 61 percent in 2019, to 69 percent in 2021.