Mortality in people with attention-deficit/hyperactivity disorder (ADHD): Examining how risk is embodied in a pooling of two prospective cohort studies
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Background
Nascent findings suggest that people with attention-deficit/hyperactivity disorder (ADHD) experience higher rates of mortality. To date, study samples have been insufficiently well-characterized to examine the mechanisms via which this neurodevelopmental condition elevates mortality risk.
Methods
We used data from the 2007 and 2011 waves of the US National Health Interview Survey, a general population-based cohort study comprising 52097 adults (28675 women) aged 18 years or older at baseline. ADHD diagnosis and an array of demographic, socioeconomic, lifestyle, and co-morbidity (somatic and psychiatric) covariates were self-reported.
Findings
At baseline, compared with unaffected individuals, participants with ADHD were more likely to be socioeconomically disadvantaged, smoke cigarettes, consume alcohol, and report symptoms of psychological distress. A median 7.75 years of mortality surveillance (range: 7.25-12.25) gave rise to 6597 deaths from all-causes. After adjustment for age, sex, ethnicity, and survey year, ADHD was associated with a markedly elevated risk of death (hazard ratio [95% confidence interval]: 1.58 [1.20-2.09]). Statistical adjustment for socioeconomic circumstances (11% attenuation), physical co-morbidities (15%), and lifestyle factors (17%) had only a modest impact on the ADHD–death gradient, with the greatest explanatory power apparent for symptoms of depression and anxiety (58%). The magnitude of the association of ADHD with mortality was commensurate to that for several well-established risk factors such as poverty (1.66 [1.55-1.78]), hypertension (1.41 [1.32-1.51]), and diabetes (1.71 [1.59-1.85]) but somewhat lower than cigarette smoking (2.51 [2.29-2.76]) after controlling for age, sex, ethnicity, and survey year. Associations between ADHD and cause-specific mortality from cardiovascular disease, cancer, and chronic respiratory disease were inconclusive.
Interpretation
In the present study, the influence of ADHD on total mortality appears to be largely embodied via a series of malleable characteristics, particularly mental illness. If confirmed elsewhere, these results raise the possibility that risk factor modification via standard pharmacological and behavioral interventions could help reduce rates of premature mortality in this patient group.
Funding
This paper received no direct funding. GDB is supported by the UK Medical Research Council (MR/P023444/1) and the US National Institute on Aging (1R56AG052519-01, 1R01AG052519-01A1).
Research in context
Evidence before this study
We searched the PubMed database (January 1947 to June 2026) using the terms ‘attention-deficit/hyperactivity disorder ‘, ‘ADHD’, ‘mortality’, and ‘death’ with no language or date restrictions. We considered individual studies, systematic reviews, and meta-analyses. The most recent systematic review was published in 2022 and the majority of the eight non-overlapping studies found that ADHD was associated with a raised risk of mortality. Included cohort studies were typically generated from linked administrative health records and therefore insufficiently well characterized to comprehensively test how ADHD was embodied in order to elevate death rates. There was some suggestion of a role for mediation via socioeconomic position and mental illness but lifestyle factors such as obesity, smoking, physical inactivity, and alcohol intake had not been considered. A side-by-side comparison of the magnitude of the relationship of ADHD with conventional risk factors for mortality was also lacking.
Added value of this study
This is the first prospective cohort study to systematically and comprehensively test the mechanisms via which ADHD elevates mortality and to contextualize the strength of this relationship against well-established risk factors. Socioeconomic circumstances, physical co-morbidities, and lifestyle factors mediated less than one fifth of the ADHD–death gradient, with the greatest explanatory power apparent for depression and anxiety. The impact of ADHD on mortality risk was commensurate to that apparent for several well-established risk factors for mortality such as poverty, hypertension, and diabetes but somewhat lower than estimates for cigarette smoking and physical inactivity.
Implications of all the available evidence
While supporting evidence is required, our findings point to the possibility that modification of physical co-morbidities, lifestyle factors, and mental illness via pharmacological treatment and behavioral intervention may have utility in the avoidance of premature mortality in people with ADHD.
