2026 ECNP Congress

PS01-1134

Gender bias in diagnosis and treatment planning of adult ADHD: a randomised vignette study among Turkish psychiatrists

Pinar Kizilay Çankaya — E. Uysal, M. Metin, A. Kandeğer · Gazi University- Institute of Health Sciences, Medical Pharmacology, Ankara, Türkiye

2026 ECNP Congress

Introduction

Attention-deficit/hyperactivity disorder (ADHD) is consistently underdiagnosed in adults, particularly women, who more often present with inattentive symptoms and emotional dysregulation [1, 2]. These features are frequently misattributed to personality disorders or other comorbidities, which may mask underlying ADHD symptoms with profound psychosocial consequences [1, 2, 3]. While randomised vignette studies have demonstrated gender bias in pediatric ADHD diagnosis [4], experimental evidence specifically regarding adult ADHD diagnosis within Turkish psychiatric practice has not been previously established [5].

Aims

This study aimed to experimentally examine whether patient sex influences ADHD diagnosis rates, alternative diagnosis patterns, and treatment planning among Turkish psychiatrists, while exploring associations between clinician characteristics and diagnostic behaviour.

Methods

A randomised between-subjects vignette study was conducted via the Qualtrics platform among 218 specialists and trainees in psychiatry (≥2 year of training; median age 32.5 years (IQR: 29–37); 65.1% female; 43.6% residents) from 44 cities across all seven geographical regions of Türkiye. The experimental vignette depicted a 31-year-old graduate presenting with emotional dysregulation, inattention, impulsivity, functional impairment, and suboptimal antidepressant response. The case was designed to meet DSM-5 criteria for ADHD while incorporating overlapping features of borderline personality disorder (BPD), and was reviewed and refined by ten experienced specialists. Participants were excluded if they failed an initial control vignette. Eligible participants were randomised to either a male (n=109) or female (n=109) version of the vignette, with sex as the sole manipulated variable. Statistical analyses included Chi-square tests for categorical diagnosis rates, Wilcoxon signed-rank tests for recognisability ratings, and Spearman’s rank correlations for clinician characteristics. An a priori power analysis indicated a required N=197 (w=0.20, 1-β=0.80); the current sample size exceeds this threshold.

Results

ADHD diagnosis rates did not differ significantly by patient sex (male: 51.4% vs. female: 46.8%; χ²=0.459, p=0.498). BPD was the most frequently assigned diagnosis after ADHD in both groups (male: 46.8%; female: 49.5%). Bipolar disorder was assigned numerically more often in the female condition (6.9% vs. 1.9%). Treatment planning did not differ by patient sex, with stimulant medication recommended in over 80% of cases regardless of patient sex. Female clinicians diagnosed ADHD significantly more often than male clinicians (54.9% vs. 38.2%; χ²=5.572, p=0.018). ADHD was rated as substantially less recognisable in women than men (median 4 vs. 6 out of 10; p<0.001, r=0.718). While professional experience correlated with self-rated knowledge (rs=0.308, p<0.001), competency (rs=0.378, p<0.001), and perceived female recognisability (rs=0.155, p=0.022), it did not predict actual diagnostic behaviour.

Conclusions

Clinician sex appears to be a stronger predictor of diagnostic tendency than patient sex in this sample. BPD predominantly displaced ADHD as the primary diagnosis regardless of patient sex, reflecting the inherent symptomatic overlap between these conditions [1, 3]. The significant gap between clinicians’ theoretical awareness of female underrecognition and their actual diagnostic behaviour suggests a clinical “blind spot” driven by implicit rather than explicit bias. These findings underscore that knowledge alone is insufficient to change practice; structured gender-informed clinical training and objective diagnostic tools are warranted [5].

References

  1. Attoe, D.E., Climie, E.A., 2023. Miss. Diagnosis: A Systematic Review of ADHD in Adult Women. J. Atten. Disord. 27 (7), 645–657.
  2. Young, S., Adamo, N., Ásgeirsdóttir, B.B., et al., 2020. Females with ADHD: An expert consensus statement taking a lifespan approach providing guidance for the identification and treatment of attention-deficit/hyperactivity disorder in girls and women. BMC Psychiatry 20 (1), 404.
  3. Weiner, L., Perroud, N., Weibel, S., 2019. Attention Deficit Hyperactivity Disorder And Borderline Personality Disorder In Adults: A Review Of Their Links And Risks. Neuropsychiatr. Dis. Treat. 15, 3115–3129.
  4. Bruchmüller, K., Margraf, J., Schneider, S., 2012. Is ADHD diagnosed in accord with diagnostic criteria? Overdiagnosis and influence of client gender on diagnosis. J. Consult. Clin. Psychol. 80 (1), 128–138.
  5. Özel, B., Karakaya, E., Köksal, F., et al., 2024. Gender bias of antisocial and borderline personality disorders among psychiatrists. Arch. Womens Ment. Health 28 (3), 563–571.