Background
Although often intended for long-term treatment, discontinuation of medication for ADHD is common. However, cross-national estimates of discontinuation are missing due to the absence of standardised measures. The aim of this study was to determine the rate of ADHD treatment discontinuation across the lifespan and to describe similarities and differences across countries to guide clinical practice.

Methods
We did a retrospective, observational study using population-based databases from eight countries and one Special Administrative Region (Australia, Denmark, Hong Kong, Iceland, the Netherlands, Norway, Sweden, the UK, and the USA). We used a common analytical protocol approach and extracted prescription data to identify new users of ADHD medication. Eligible individuals were aged 3 years or older who had initiated ADHD medication between 2010 and 2020. We estimated treatment discontinuation and persistence in the 5 years after treatment initiation, stratified by age at initiation (children [age 4–11 years], adolescents [age 12–17 years], young adults [age 18–24 years], and adults [age ≥25 years]) and sex. Ethnicity data were not available.

Findings
1 229 972 individuals (735 503 [60%] males, 494 469 females [40%]; median age 8–21 years) were included in the study. Across countries, treatment discontinuation 1–5 years after initiation was lowest in children, and highest in young adults and adolescents. Within 1 year of initiation, 65% (95% CI 60–70) of children, 47% (43–51) of adolescents, 39% (36–42) of young adults, and 48% (44–52) of adults remained on treatment. The proportion of patients discontinuing was highest between age 18 and 19 years. Treatment persistence for up to 5 years was higher across countries when accounting for reinitiation of medication; at 5 years of follow-up, 50–60% of children and 30–40% of adolescents and adults were covered by treatment in most countries. Patterns were similar across sex.

Interpretation
Early medication discontinuation is prevalent in ADHD treatment, particularly among young adults. Although reinitiation of medication is common, treatment persistence in adolescents and young adults is lower than expected based on previous estimates of ADHD symptom persistence in these age groups. This study highlights the scope of medication treatment discontinuation and persistence in ADHD across the lifespan and provides new knowledge about long-term ADHD medication use.

Funding
European Union Horizon 2020 Research and Innovation Programme.