ADHD in Adults Service Development

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1 ADHD in Adults Service Development March 23, 2016 East Midlands Mental Health Commissioning Network Conference Muhammad Arif Leicestershire Partnership NHS Trust

2 Services for Adults with ADHD a defining moment

3 long-term outcomes A systematic review and analysis of long-term outcomes in attention deficit hyperactivity disorder: effects of treatment and non-treatment Monica Shaw1, Paul Hodgkins2*, Hervé Caci3, Susan Young4, Jennifer Kahle5, Alisa G Woods6 and L Eugene Arnold7 Results: Outcomes from 351 studies were grouped into 9 major categories: academic, antisocial behaviour, driving, non-medicinal drug use/addictive behaviour, obesity, occupation, services use, self-esteem, and social function outcomes. The following broad trends emerged: * without treatment, people with ADHD had poorer long-term outcomes in all categories compared with people without ADHD 3

4 implications of un-treated ADHD schooling: suspensions 60% Barkley et al 2006 drop outs 32% excluded x 11 work: lower status jobs/multiple changes Mannuzza et al 1997 reduced productivity Noe & Hankin et al

5 implications of un-treated ADHD relationships++ -early parenthood..15 vs 16 Barkley et al 1993; Leibson et al sexual partners..19 vs 7 Barkley pregnancy..34% -STDs..13% families -parental frustration -marital discord Barkley et al divorce/separation x 3-5 Brown et al mental health issues -loss of working days/productivity Noe & Hankin

6 implications of un-treated ADHD criminal justice system Young et al court proceedings -probation -prison ++ substance-misuse: higher rates Biederman et al 1998 driving: violations/accidents x 4 Barkley et al 1996 injuries: x 3-4 Stewart et al 1966, Mitchell et al 1987 GP/A & E Lepson et al 2001 QOL 6

7 suicide Ljung T et al JAMA n: 51,707 - increased risk of attempted & completed suicide: OR 3.62 & 5.91 parents: OR 2.42 & 2.24 siblings: OR 2.28 & also increased risk of completed suicide in first degree relatives 7

8 mortality Dalsagaard et al Danish National Register: 1.92m (32,061 ADHD); 32 yr follow-up deaths -mortality rate per 10,000: ADHD 5.85 vs non-adhd 2.21 MRR after exclusion of ODD/CD, SUDs: MRR 1.5 -higher in adults and girls/women -accidents Barbaressi et al 2013

9 co-morbidity in Dutch series of 141 adult ADHD cases % had one other disorder Mood disorders Drug abuse/dependency Anxiety disorders Antisocial PD Borderline PD Mood symptoms Anger outbursts Sensation seeking Dusrupted sleep patterns Depressive complaints Anxiety Aggression Hypersensitivity to noise DISORDERS SYMPTOMS Kooij JJ,

10 rates of ADHD within adult mental health services 30% 25% 20% 15% 10% 5% 0% Prisons (26%) Addiciton (12%) Anxiety D (6%) Forensic (PD) (12.9%) Primary care (11.6%) General psych (15.3%) Murphy et al., NIHR report, 2013; Deberdt et al., BMC Psychiatry, 2015;

11 services for adults with ADHD why? 11

12 June yrs old male attending day hospital re: anxiety disorder very poor concentration restless/fidgety 13 jobs in 18 months 12

13 setting Up and running ADHD service local situation & arrangements CCG/Health Authority NHS Mental Health Trusts/Foundation Trusts clinicians preparedness funding service model shared care protocols/agreements training 13

14 service models * NICE -Tertiary Service Model (Specialist Neuro-developmental Services) - Generic Service Model * Leicester Model Combined (Secondary + Tertiary) Service Model 14

15 Leicester Model Care pathways General Adult Psychiatry Shared Care Agreement Transition Agreements (CAMHS/Comm. Paediatrics) Shared-Care Protocol Primary Care >Medicine Strategy Group 15

16 *In some cases referrals from within Psychiatric Services would not require an initial assessment by the (sector) General Adult Psychiatry Team except for allocation of care coordinator. ADULT ADHD CARE PATHWAY NEW UNDIAGNOSED PATIENTS G. PRIMARY CARE H. GENERAL ADULT PSYCHIATRY I. OTHER TEAMS FROM WITHIN PSYCHIATRIC SERVICES/LPT* General Adult Psychiatry Team/CMHT to carry out initial assessment as outlined in Services for Adults with ADHD Leicester Model Specialist Adult ADHD Clinic/Team to carry out full assessment and when necessary initiate, stabilise and monitor treatment following principles outlined in NICE guidelines. The overall care to be provided by the General Adult Psychiatry Team/CMHT on principles outlined in Services for Adults with ADHD Leicester Model Transfer of care to General Adult Psychiatry Team/CMHT as outlined in Services for Adults with ADHD Leicester Model At a later stage in service delivery re: shared care protocols with Primary Care, certain group of patients who are stabilised and do not present with any ongoing unmet needs or complexities may be discharged to Primary Care with backup support from the Specialist Services (Secondary/Tertiary) At a later stage following a period of further training General Adult Psychiatry Team/CMHT will be in a position to take up new assessments and when necessary initiate and monitor treatment for adults with ADHD As mentioned in the Services for Adults with ADHD Leicester Model, at this stage the role of Specialist Adult ADHD clinic/team will be revised to a back up support providing second opinions on assessment and/or treatment of complex presentations

17 General Adult Psychiatry Shared Care Agreement Joint care -general adult psychiatry: overall care -specialist adult ADHD clinic: ADHD care General Adult Psychiatry -initial screening assessment -co-morbidities -continuation of prescription -d/c of stabilised patients 17

18 Leicester Model-Transition 1. initial referral letter from CAMHS: adult CMHT/ adult ADHD clinic 2. *adult ADHD clinic to take the lead *adult CMHT to co-work 3. allocation of care coordinator (adult CMHT) 4. complex cases: joint work 5. adult ADHD clinic to monitor interim 6. complete transfer of care to adult CMHT * Not to D/C the patient until seen by adult services 18

19 Shared Care Protocol Primary Care referral letter continuation of prescription discharge of stable patients back to primary care with an arrangement for annual review 19

20 progress referral rate: 20/week caseload: 800+ discharge back to general psychiatry/primary care prescription continued by primary care SpR training consultant visits/shadowing new assessments/treatment at sector level ADHD/Adult ADHD interest group/peer supervision group 20

21 future training peer supervision/networking clinical governance research second opinion.. regional/national expertise expansion of service support groups 21

long-term outcomes A systematic review and analysis of long-term outcomes in attention deficit hyperactivity disorder: effects of treatment and non-treatment Monica Shaw1, Paul Hodgkins2*, Hervé

22 long-term outcomes A systematic review and analysis of long-term outcomes in attention deficit hyperactivity disorder: effects of treatment and non-treatment Monica Shaw1, Paul Hodgkins2*, Hervé Caci3, Susan Young4, Jennifer Kahle5, Alisa G Woods6 and L Eugene Arnold7 Results: Outcomes from 351 studies were grouped into 9 major categories: academic, antisocial behaviour, driving, non-medicinal drug use/addictive behaviour, obesity, occupation, services use, self-esteem, and social function outcomes. The following broad trends emerged: *treatment for ADHD improved long-term outcomes compared with untreated ADHD, although not usually to normal levels 22

23 it has changed my life in their own words the fog has cleared I can now think clear I don t do the last minute rushing anymore I now have spare time I now walk my children to school the quality of my family life is so much better now I am so much more organised and efficient now for the first time ever my in-tray is regularly empty I walk away from trouble...it is not worth it for the first time I can now think before I say or do things

Dr S H Jawed Consultant General Adult Psychiatrist, Dorothy Pattison Hospital, Walsall Joint Lead Consultant for

Dr S H Jawed Consultant General Adult Psychiatrist, Dorothy Pattison Hospital, Walsall Joint Lead Consultant for Dr S H Jawed Syed.Jawed@dwmh.nhs.uk 01922607039 Consultant General Adult Psychiatrist, Dorothy Pattison Hospital, Walsall Joint Lead Consultant for Adult Neurodevelopmental Service, DWMHP NHS Trust Regional