ADHD in adults- the Edinburgh Experience
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1 ADHD in adults- the Edinburgh Experience Dr. Premal J Shah Consultant Honorary Senior Lecturer General Adult Psychiatry University of Edinburgh Founder Lothian Adult ADHD Clinic 2012 Lothian Adult ADHD Team 2012 RCPiS working group, adults with ADHD 2015 Lothian Adult ASD Team
2 Disclosures Honoraria and sponsorship from: Shire Flynn Institute of Psychiatry, London
3 Experience of doing what with adult ADHD?
4 Challenges High prevalence: adult ADHD= ~2% of popn. High co-morbidity: 70% with at least 1 other psychiatric co-morbidity Many already embedded in mental health services and unrecognized A risk factor for other mental health problems eg EUPD (Philipsen 2006) Sleep disorders (Silvestri et al 2009) Gender identity (Strand et al 2014) Found across all adult mental health specialties
5 NDDs overlap Often co-exist from a young age (Gillberg) Often have shades of other NDDs (similar to PDs) ADHD ASD Tourette s Tic disorders D/mental Co-ord disorders Neurodevelopmental assessment may reveal other trait disorders
6 Implications for strategy Specialist service for ADHD Pros: concentrated expertise additional funding (eg commissioning) better for research Cons: requires significant resourcing artificial segmentation from other AMH services who manages the comorbidities? Invest in training existing staff More cost effective, better coverage of population Slower to develop expertise
7 Lothian Adult ADHD team Objectives: 1. Convince clinicians that adult ADHD is useful to identify and treat 2. Train services to detect and screen for ADHD 3. Develop capacity within existing services to diagnose and treat those with ADHD 4. Consultative service for more complex presentations/ second opinions 5. Develop Psycho-educational post diagnostic packages 6. Link with users/ carers
8 Lothian Adult ADHD team (2) evolution from ADHD clinic 2 consultant sessions/ week OT- 1 session/ week Psychology- 1 session/ week Admin- 1 session/ week Project lead/ management- 1 session/ week
9 Progress over 5 years (1) Training: GP practices- individually/ dusk events/ clusters General adult mental health teams Psychiatric In-patient units IHTT/ Psychiatric emergency services Consultants/ senior trainees MRCPsych course Undergraduate medical course
10 Progress over 5 years (2) Training: Specialist psychiatric services VIP, Eating disorders, Forensic, Substance misuse, Liaison, Trauma services, Brain injury General physicians Psychology Social work Occupational health services Educational institutions- Universities and colleges
11 Progress over 5 years (3) Training: Case discussion groups Specialist clinic- joint assessments with referrers Special interest sessions for higher trainees Specific joint clinics with LD, substance misuse, forensic
12 Progress over 5 years (4) Service development: Post diagnosis education package Referral pathway from primary care to AMH services Use of screening tools at point of referral Shared care protocols for ADHD medications Links with ADHD user/ carer group ADHD conference to share practice across health boards
13 Progress over 5 years (5) Impact: Adult ADHD assessments by general adult services Up to 30% of cold referrals to psychiatrists for NDD assessment (!) 1/16-1/17: 99 referrals to ADHD/ ASD team (57 ADHD, 42 ASD)
14 Future directions Integration with ASD team- provide unified approach to NDDs in adults Integrated NDD pathway Assessment/ information gathering through mental health teams (not just psychiatry) Principle of a reasonable NDD assessment Data gathering- referral rates/ diagnostic rates in Lothian Screening for NDDs in specific general adult patient groups eg EUPD
15 Screening
16 A reasonable NDD (ASD/ ADHD) assessment ADHD- the DIVA If I could be in your head, what would it be like? How many times have you lost your phone/ keys/ cards? Tell me about your reading/ writing ASD- RCP Diagnostic Interview Guide for the Assessment of ASD Are you the last one to get jokes/ unable to read between the lines? What is a friend? Tell me about your hobbies. Is it causing significant functional impairment?
17 RCPiS working group on adults with ADHD Good practice guidelines recently produced Future training workshops Scottish network/ special interest group Influence local service design Influence health policy
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