ADHD is undertreated in Brazil

LETTER TO THE EDITORS

ADHD is undertreated in Brazil

Paulo Mattos^I; Luis Augusto Rohde^II; Guilherme V. Polanczyk^III

^IAssociate Professor of Psychiatry, UFRJ

^IIFull Professor of Psychiatry, UFRGS

^IIIAssistant Professor of Child & Adolescent Psychiatry, USP

Dear Editor,

Increasing awareness about attention-deficit hyperactivity disorder (ADHD) - whether related to campaigns sponsored by medical associations, patient self-help groups or pharmaceutical companies - is associated with a desirable progressive increase in the number of patients being diagnosed and treated. However, there are concerns about overtreatment, especially in children and adolescents, which is often addressed by the media in alarming ways.

Stimulants are the first-line treatment for ADHD in school-age children, adolescents and adults. The recent increase in the sales of these pharmaceuticals in Brazil has directed the attention of the community to the possibility of overtreatment. To verify whether the total number of stimulants sold in Brazil in 2009 and 2010 correspond to a larger-than-expected number of patients with ADHD in treatment, we analyzed the available data from the only two pharmaceutical companies in the country that were marketing stimulants during that period. We estimated the number of individuals that would be under continuous treatment considering that a patient would take one single pill per day (even for immediate-release methylphenidate 10 mg, which should be administered two or three times a day) for 22 days per month for ten months per year. It is important to note that we considered the minimum number of days in use for an adequate treatment, which implies that all patients would withdraw from medications during the summer and on weekends. In 2009, 1,413,460 boxes of methylphenidate formulations were sold in Brazil, which represents 32,986,110 pills. In 2010, 1,674,372 boxes of methylphenidate formulations were sold in Brazil, which represents 40,585,870 pills (data provided by IMS Health Care Measurement). Using our very liberal definition of continuous treatment (1 pill per day, for 22 days per month, for 10 months per year), well under treatment guidelines, we calculated that up to 149,937 and 184,481 individuals could be under continuous treatment in 2009 and 2010, respectively.

We then calculated the expected number of individuals with ADHD in Brazil, taking into account the latest official population figures provided by IBGE (2010). Again, to perform an extremely conservative analysis, we considered the lowest prevalence estimate detected in a Brazilian epidemiological study (0.9%) (Goodman et al.¹), even though recent meta-analyses computed worldwide rates of ADHD approximately 5.3% for youths and 2.5% for adults (Polanczyk et al.²; Simon et al.³). Using these very conservative estimates for ADHD in the population, at least 924,732 individuals are expected to be affected by ADHD in Brazil (Table 1).

Thus, it is estimated that only 16.2-19.9% of individuals affected by ADHD in Brazil were receiving first line treatment for the disorder in 2009-2010, even given very conservative figures calculated by overestimating the number of individuals receiving continuous treatment and underestimating the number of individuals with ADHD. In fact, the real figure is likely even lower because these stimulants also have other, less frequent indications. However, it is important to note that approximately 30% of ADHD patients do not respond to stimulants and should be treated with other agents; furthermore, not all ADHD patients require pharmacological interventions. However, our extremely conservative analyses certainly counter-balance any effects of these two aspects. Concerns that an excessive number of individuals may be treated with stimulants for ADHD in our country lack any scientific basis. Further educational campaigns are needed to identify the significant proportion of untreated individuals affected by ADHD in Brazil.

• 1. Goodman R, Neves dos Santos D, Robatto Nunes AP, Pereira de Miranda D, Fleitlich-Bilyk B, Almeida Filho N. The Ilha de Maré study: a survey of child mental health problems in a predominantly African-Brazilian rural community. Soc Psychiatry Psychiatr Epidemiol. 2005;40(1):11-7.
• 2. Polanczyk G, de Lima MS, Horta BL, Biederman J, Rohde LA. The worldwide prevalence of ADHD: a systematic review and metaregression analysis. Am J Psychiatry. 2007;164(6):942-8.
• 3. Simon V, Czobor P, Bálint S, Mészáros A, Bitter I. Prevalence and correlates of adult attention-deficit hyperactivity disorder: meta-analysis. Br J Psychiatry. 2009;194(3):204-11.

Publication Dates

• Publication in this collection
  16 Jan 2013
• Date of issue
  Dec 2012