In Reply

The Changing Prevalence of Attention-Deficit/ Hyperactivity Disorder and Methylphenidate Prescriptions: A Study of Data From a Random Sample of Insurees of the AOK Health Insurance Company in the German State of Hesse, 2000–2007 by Dr. rer. soc. Ingrid Schubert, Ingrid Köster, Prof. Dr. med. Gerd Lehmkuhl in volume 36/2010

The authors thank their correspondents for their feedback. Dietrich rightly points out that the data from the health insurance companies document the disorder only for insurees with contact to their doctors and suggests to specify as prevalence estimates as “prevalence of consultations.” We dealt with this aspect in our article with the terms “treatment prevalence” or “administrative” treatment prevalence.

We agree with Dietrich that these administrative prevalence rates are lower than those obtained from population surveys, such as the Robert Koch-Institute’s German Health Interview and Examination Survey for Children and Adolescents (Kinder-und Jugend-Gesundheitssurvey, KiGGS) (1), which may include unknown cases and patients who have not consulted a doctor. However, we regard the routine data that have no selection bias or recall bias as an important addition to the surveys, which can only be conducted at greater time intervals owing to their high cost.

In the discussion section we point out that treatment with methylphenidate is regarded as a public health problem in many countries. From the context it is clear that this statement relates to the increase in prescriptions observed in many countries and thus to the background phenomenon of an increase in diagnoses with all its social, medical, and health economic problems. At no point in the article did we refer to indication conform treatment as a problem.

We showed in our study that not every coded diagnosis results in a prescription for stimulants. However, the proportion of prescriptions for drug treatment has risen from 35.5% in 2000 to 48% in 2007. Dietrich’s assumption that other psychiatric disorders have higher prevalence rates of drug treatment does not provide any clues about the quality with which the indication was defined. Börner also mentions how difficult it is to reach a diagnosis and assumes that the diagnosis is possibly made only on the basis of the effects of MPH. We cannot comment on this because we cannot conclude this from the available data.

The extent to which ADHD is solely genetically determined or whether it is multifactorial in origin (2) was not the subject of our study and we can therefore not discuss it here. However, as Neraal illustrates by explaining the results of a recent Swedish study, many studies have shown an association between socioeconomic class and the development of psychiatric disorders. This applies to Germany too, as detailed in the KiGGS: the lower someone’s socioeconomic status, the more often they received a diagnosis of ADHD (1).

DOI: 10.3238/arztebl.2010.0919b

Dr. rer. soc. Ingrid Schubert

PMV forschungsgruppe an der Klinik und Poliklinik

für Psychiatrie und Psychotherapie des Kindes- und Jugendalters

Universität zu Köln

Herderstraße 52

50932 Köln

Conflict of interest statement
PMV research group has received project funding from statutory sickness funds, foundations, and pharmaceutical companies ( Sanofi-Aventis, Novo-Nordisk, Lilly, Sanofi-Pasteur-MSD, Bayer-Schering, Merz, Janssen-Cilag, Abbott). Dr Ingrid Schubert and Ingrid Köster have not received personal honoraria. Professor Dr Gerd Lehmkuhl has received research funding from Lilly Germany and Bristol-Myers Squibb’; he is a member of the advisory board of Eli Lilly Strattera.

References

1. Robert-Koch-Institut (ed): Lebensphasenspezifische Gesundheit von Kindern und Jugendlichen in Deutschland. Ergebnisse des Nationalen Kinder- und Jugendgesundheitssurveys (KiGGS). Beiträge zur Gesundheitsberichterstattung des Bundes. Robert Koch-Institut Berlin, 2008.

2. Sachverständigenrat für die Begutachtung der Entwicklung im Gesundheitswesen. Koordination und Integration – Gesundheitsversorgung in einer Gesellschaft des längeren Lebens . Sondergutachten 2009

3. Schubert I, Köster I, Lehmkuhl G: The changing prevalence of attention-deficit/hyperactivity disorder and methylphenidate prescriptions: A study of data from a random sample of insurees of the AOK health insurance company in the german state of Hesse, 2000–2007. Dtsch Arztebl Int 2010; 107(36): 615–21.