Adult ADHD: How Big is the Problem? Delivering Effective Services for Adults with ADHD
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1 Adult ADHD: How Big is the Problem? Delivering Effective Services for Adults with ADHD North West Mental Health Commissioning Network 1 st March 2016 Dr Prathiba Chitsabesan Consultant Child and Adolescent Psychiatrist and Clinical Director (Pennine Care NHS Foundation Trust) Honorary Lecturer (University of Manchester- Offender Health Research Network) Clinical Advisor CAMHS Advisory Group (SCN)
2 Presentation ADHD Persistent and pervasive pattern of hyperactivity, inattention and impulsivity across settings George Still (1902) in children but studies on adults delayed until 1960 s US- initially called MBD Aetiology Neurobiological disorder- polygenetic (70-80% heritability) and environmental factors Dopamine and noradrenaline transmission disrupted in particular pathways including prefrontal cortex Definition/Diagnosis ICD-10- Hyperkinetic Disorder Early onset, persistent over time, pervasive across settings and associated with severe impairment DSM-V Changes from DSM-IV- lower threshold needed to meet diagnosis in adults
3 Epidemiology Prevalence Prevalence- 5% of children and young people (broader DSM criteria) and 1.5% (ICD-10); M>F- 4:1 Follow-up studies of ADHD in children (Farone et al., 2006) 15% retaining a full diagnosis by 25 years, further 50% retaining some symptoms leading to continued impairments in daily life Adults NICE (2008) % full criteria and 2-4% partial remission Pooled prevalence -2.5% (Simon et al., 2009) General Adult Psych OP Clinic North East England- 22% (Rao et al., 2011)
4 Co-morbidity Co-morbidity high in adults with ADHD (80%) for mental health needs and neurodevelopmental disorders UMASS Study (US Study) Depression 36% Generalised anxiety 27% Alcohol abuse/dependency- 36% Substance abuse/dependency- 34% Polderman et al., 2014 (Swedish study) 28-44% of adults with Autism Spectrum Disorder met criteria for ADHD Phillipsen et al.., 2008 (Dutch Study) 16% of female patients with Borderline Personality Disorder met criteria for ADHD Klein et al., 2009 (US Study) 47% of male patients with Antisocial Personality Disorder met criteria for ADHD
5 Impact Multiple domains Functioning- occupational, educational, money management Relationships- partners/marriage Mental health needs (mood disorders/aspd/ substance misuse) and risk of self-harm Physical health needs- higher rates of CVS, cancer (smoking), alcohol related disease, driving accidents, STDs, teenage pregnancy and premature mortality Increased association with offending- violent/persistent offending Cost to adult, family, services and public sector substantial long-term cost on society, estimated at around 100,000 per case-two-thirds of the cost takes the form of additional public expenditure on education and health care, with the remainder being reflected in reduced earnings (Centre for Mental Health, 2014).
6 Guidelines and Recommendations
7 Referral and Assessment NICE (2008) and Quality Statement 2: Identification and referral in adults (NICE, 2013) In recognition of adults with undiagnosed ADHD Commissioners should ensure that they commission specialist services for the assessment of adults with suspected ADHD Primary care/health and social care practitioners should be able to recognise and refer adults with symptoms of ADHD for specialist assessment Specialist teams should provide training to community and partner agencies around symptoms (primary care, AMHS etc) Specialist ADHD teams should be multi-disciplinary Assessment by a psychiatrist or mental health specialist with training, experience and knowledge of ADHD Full clinical and psychosocial assessment Assessment of co-morbidity and needs
8 Pharmacological Treatment First line treatment for adults with Moderate and Severe ADHD Pharmacological Choice of stimulants (methylphenidate and dexamphetamine) and non stimulants (atomoxetine) Effectiveness- Large effect size as for children (Faraone and Glatt, 2009) 60-70% adults respond to medication treatment Licensing Increasing number of medications licensed for use in adults Monitoring Cardiovascular changes such as increased pulse and blood pressure need to be monitored, although this is similar to many other drugs used in adults. Summary Appropriate funding to support care pathways including medication titration costs Development of SCPs Agreement between primary and specialist services in monitoring medication
9 Psychological Treatment NICE (2008) recommends adults with ADHD require integrated care that addresses a wide range of personal, social, educational and occupational needs Drug treatment for adults with ADHD should always form part of a comprehensive treatment programme Psycho-educational programmes are increasingly available for ADHD (selfhelp material) Cognitive behavioural therapy for Adult ADHD Less cost-effective in comparison to medication but opportunities for group interventions e.g CBT NICE (2008) suggest addition of CBT to medication for persistent symptoms Ensure treatment of co-morbidity CBT may be useful for those with co-morbid mood disorders Developing evidence for adult offenders with ADHD (R and R2)
10 Treatment Outcomes Addressing ADHD may have a three-fold impact: 1. Directly reducing symptoms 2. Improving occupational and social functioning 3. Reducing poor secondary mental health and physical health outcomes High risk populations The treatment of underlying ADHD may lead to improvements in comorbid disorders (substance abuse disorders including addiction, and anxiety and depression including the risk of suicide) Offenders/Crime 24% childhood ADHD, 6% full criteria in adulthood and 8% partial remission (Young et al., 2009) ADHD Treatment in adult offenders reduced reoffending by 32% for men and 41% for women (Lichtenstein et al., 2012)
11 Need for Change! Development of SCN Guidance for Children and Young People (2015) GM Mental Health Strategy Development of ADHD Lifespan Services
12 1. Service Planning 1. Identification of need and unmet need 3 main groups of service users to consider: Diagnosed and stabilized on medication from CAMHS/Paeds ADHD services Previously diagnosed in childhood and re-referred for medication treatment Referred for assessment and treatment 2. Multi-agency working and co-commissioning 3. Developing training programmes Primary care, community and specialist services 4. Workforce design and planning Capacity, confidence and competence in workforce across primary and specialist services
13 2. Referral from Community Services 1. Development of a multi-agency care pathway through local stakeholder events outlining the contribution of different stakeholders to the pathway 2. Stepped care model before referral of a adult with possible ADHD for assessment Initial screening role of rating scales (e.g Connors/ASRS) Support within the community for adults (strategies/advice) 3. Develop care pathways dependent on: ADHD Assessment and Treatment Needs Diagnosed and stabilised on treatment Needs medication stabilisation Needs assessment and treatment Co-morbidity (mental health/neurodevelopmental/offending)
14 3. Specialist Assessment 1. Specialist teams should be multi-disciplinary and consider the role of specialist ADHD nurses to provide more cost-effective models of care 2. ADHD nurses should act as a named contact for other services in Providing consultation and advice 3. Key differences from NICE (2008/13):- Role of standardised assessment protocol/screening tool for other practitioners (AMHS/SM teams) Investment in objective psychometric assessments to aid reliability of diagnosis and standardise care
15 4. Interventions 1. Behavioural interventions including self-help information should be available to adults Information and signposting Behavioural interventions for adults (role of voluntary and 3 rd Sector) Psycho-education Advice on strategies Use of Apps/technology Review group CBT (for those on medication with persistent symptoms and motivated)
16 4. Interventions 2. Pharmacological treatment should be monitored within ADHD clinics Local agreement between commissioners, specialist and primary care services regarding the role of each stakeholder in monitoring and prescribing through the use of shared care protocols Specialist services to consider role of ADHD nurses/advanced practitioners in cost-effective models of medication monitoring Monitor outcomes through the use of validated ADHD symptom scales e.g Connors/Wender Utah/ ADHD-RS IV) quality of life measures changes in functioning e.g sustaining employment possible role of objective measures (Qbtest for treatment optimisation)
17 Overwhelmed?
18 Confused?
19 Partnership Working
20 Thankyou
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