Adults with ADHD Clinical and service conundrums

Transcription

1 Adults with ADHD Clinical and service conundrums Dr Prem Shah, Consultant General Psychiatry Honorary Senior Lecturer Lead, Lothian Adult ADHD Clinic

2 6 general psychiatrists met an adult with ADHD One said it was a snake, and tried to charm it One said it was a rope, and tried to coil it One said it was a tree, and tried to walk under it One said it was a fan, and tried to fold it One said it was a wall, and tried to climb over it And one said it was a spear, and tried to throw it! They bickered and quarrelled. They could not agree.

3 The missing (treatment resistant) elephant in the room

4 Adults with ADHD- an example (1) 36 year married man-unemployed, 2 children, black sheep of the family longstanding difficulty with his temper. Problems: 1.Education- expelled several times because of bad behaviour/ disrupting classesschool reports if only he tried harder - described as pathetic.?dyslexia 2.The law- stealing cars impulsively, unpaid court fines, unprovoked fights, violence, court appearances ++ 3.Work- 30+ jobs in 10 years- usually sacked or left on impulse, poor time-keeping, unable to hold his tongue, unable to follow instruction, impatient and irritable with bosses, kept forgetting things 4.Drugs and alcohol- referral to alcohol and drug services- DNA 5.Finance- unpaid bills, no apparent regard for managing money 6.Domestic- a hazard in the kitchen (leaves gas on), cannot shop Relationships- impulsive fights/ few friends. Very poor timekeeping (eg regular DNA at doctors, at lawyers), wife about to leave him.

5 Adults with ADHD- an example (2) 8. Psychiatric problems- previously referred to psychiatry- diagnosed as having an antisocial personality disorder / depression. Has marked mood swings. Previously prescribed antidepressants- not effective. 9. When interviewed- appeared indifferent, anxious and restless. Manner somewhat abrupt and irritable. Unable to tolerate more than half an hour of interview. Not particularly interested in the interview. Describes mood as fluctuating hugely Standard view: a.antisocial from a young age. b.past alcohol and drug user c.possible depression in the past. --> not sure what can be done to help

6 Why is it important? Costs vs Benefits- a rough estimate Cost of assessment and follow-up 400 Cost of 1 year treatment (medication) 720 Total Cost 1120 Assume back to work (median wage): Saving on benefits ( 138/ week) 7,176 Saving on 1 sheriff court case 3,000 (NB 6 months prison= 20,000) Total public savings 10,176 Net Savings c. 9,000

7 We re sceptical because: Conventional wisdom and clinical experience Does it exist? Because it could be explained by so many other things Because everyone could be defined as having it Because it could involve prescribing stimulants, for an unknown length of time Because it could encourage using dangerous drugs recreationally Because we have had little experience of recognizing and managing it

8 But our CAMHs colleagues Does exist and can persist into adulthood Up to 50% need on-going treatment ( referrals to adult services) Relatives of children with ADHD who themselves have traits ( referral to adult services) Adult services say they do not having sufficient skills/ knowledge Convincing research evidence: that treatments continue to work for some (eg BAP guidelines) that treatments may reduce other mental health issues

9 So what s the problem? ADHD in Adults Does it exist in Adults? Are we not pathologicising normality? Is it a disorder/ diagnosis? Could it not be a type of personality disorder? YES YES YES & NO YES

10 It does not exist- ADHD is a new, made up concept, the work of big pharma

11 ADHD traits recognized in children pre-ritalin... Fidgety Phil and Johnny Head-in-the-air Poems by Dr Heinrich Hoffman, 1844 Before Ritalin i.e. NOT a new phenomenon

12 and recognized in adults Scottish CAMHs (ADHD SOS project NQIS, 2007) no NHS adult ADHD service in any Board area PUPs (ADHD Project User and Parent/carer Subgroup, 2008) comparable services for children becoming adults In the scientific press- 2% of adults?

13 Pathologicising normality- how can it be a disorder? BECAUSE: ADHD= Inattention, Impulsivity, Hyperactivity AND Everyone has these traits - can you justify a valid cut-off? Can be useful ( hunter-gatherer theory) Highly genetic Highly conserved

14 The concept of a disease/ disorder Disorder Courtesy Phil Asherson Date of Prep: June 2012 Ref: UK/CON/2012/0162

15 The situation with ADHD Dx threshold For ADHD 10% of Cases 50% of Cases Normal variation in activity and attention Courtesy Phil Asherson Date of Prep: June 2012 Ref: UK/CON/2012/0162

16 Medicalising normality is not new Being normal is a risk factor Increasing risk of specific 2y consequences Increasing NET benefit of PRIMARY Intervention People with the 'diagnosis' Mean Blood pressure Cholesterol Blood glucose Diagnostic threshold line (can vary- US vs UK)

17 Perhaps ADHD is a risk factor, NOT a diagnosis

18 The Risks Other mental health problems 60-70% Poor/ no employment 60-70% Alcohol and drug misuse RTAs Divorce Healthcare costs Double Triple Quadruple Double Incarceration (%age prison population) 15-20%

19 Risks associated with high ADHD traits Date of Prep: June 2012 Ref: UK/CON/2012/0162

20 Social, Emotional, and Cognitive Risks

21 Implications (1) 1. Not all those with 'diagnostic criteria' ADHD will have 'x' (not all those with a systolic >140 will have a stroke) 2. Not all those with 'x' will have ADHD (not all those with a stroke will have a systolic>140) 3. Not having ADHD does not mean you won't have 'x' (a systolic<140 does not mean you won't have a stroke) 4. To prevent all 'x' 2y to ADHD, must have no ADHD traits (to prevent all strokes 2y to HBP, must have no BP)

22 Implications (2) A.Intervention = 2y prevention, NOT 1y. A.Intervention may NOT succeed in prevention, merely reduces risk A.Stop intervention --> likely stop the preventative effects A.Responsibility = the individual NOT the 'diagnosis' Because: ADHD is part of the normal spectrum Patient knows what can help to reduce risk Patient knows the risks of stopping Rx The individual is responsible for managing HIS/ HER risk factor

23 ADHD and personality disorder- a comparison NDDs eg ASD, ADHD Personality disorders Pervasive maladaptive traits present from <7 years old Impairment in 2 areas or more of function Traits distributed in a continuum in population Traits recognised as one end of a spectrum increased risk of secondary morbidity Pathologicising normality? Assessment usually requires > 1 interview, esp informants Specific drugs can modify/ ameliorate traits in ADHD (not ASD, yet) ADHD = personality traits that CAN be modified pharmacologically? Pervasive maladaptive behaviour trait established in childhood Cause distress to others or to the individual Traits distributed in a continuum in population PD regarded as one end of the continuum increased risk of secondary morbidity. Pathologicising normality? Assessment usually requires > 1 interview, esp informants Are there any specific drugs?

24 Pathologicising normality Is modifying normal behaviours with drugs ethical? 'cosmetic psychopharmacology' Voluntary rx: patient's decision patient's responsibility Doctor's role: advise on benefits and cost weigh up if patient can use Rx responsibly Benefits: Costs: it could help Increased personal responsibility Increased legal implications negative effects Is it ethical to bar access to a treatment that could help some one who wants to change? Is psychotherapy any more ethical? (cosmetic psychotherapy...'not my fault, it's the way I was brought up')

25 Practical Implications 4 necessary conditions: Significant ADHD traits since young? Significant 2y consequences? Likely to benefit from intervention? Is the person willing to manage it responsibly?

26 Deploying medication through the ADHD clinic 1.Do the drugs work more than placebo? 1.Dangers and risks associated with use. A. Side effects B. Addiction/ dependancy C. Diversion D. Tolerance/ dose escalation

27 Placebos please! Placebo- (lat.) 'I will please' Psalm 114, 9th verse: 'Placebo Domino in regione vivorum' I will please the Lord in the land of the living Anonymous Medieval flatterers sang at funerals, in the expectation of receiving alcohol at the wake Chaucer: 'Flatterers are the Devil's chaplains that singeth ever Placebo' Thus, Psalm 114 flatterers pleasing doctors placebo pills Do stimulants and the 'specialist clinic process' do more than 'please the patient'?

28 Experiences from Lothian Adult ADHD Clinic Drug Treatment Abuse potential - dependant on which drug and formulation- seems low in patient group- slow release less potential abuse Prescribing- is off-label with the exception of Concerta XL and Atomoxetine which can be continued into adulthood if symptoms persist. BNF states unlicensed use of medicines becomes necessary if the clinical need cannot be met by licensed medicines: such use should be supported by appropriate evidence and experience Also alters (increases) the doctor s professional responsibility BAP guidelines could be utilized to meet point A, within specialist psychiatric services.

29 The Lothian Adult ADHD Clinic

30 P Shah 4/2012 The Lothian Adult ADHD Clinic

31 P Shah 4/2012 The Lothian Adult ADHD Clinic

32 The Lothian Adult ADHD Clinic 67% starting Rx were unemployed P Shah 4/2012

33 P Shah 4/2012 Over 50% had 2+ other mental health problems

34 Drug treatment 1.Lothian Adult ADHD Clinic (drug Rx only) 350 referrals in 3.5 years Diagnosed in clinic and recommended treatment 67% were unemployed With treatment, 70% went back to work/ education 1.Randomised double-blind placebo-controlled trial of MPH in adult male prisoners with ADHD (2012): NNT= 1.1 (highly effective) (NNT for moderate High blood pressure= 52) 2.Scientific literature Level 1 evidence that treatment works

35 Date of Prep: June 2012 Ref: UK/CON/2012/0162

36 P Shah 4/2012

37 Experiences from Lothian Adult ADHD Clinic Assessment of undiagnosed adults takes time at least 2X one hour interviews neurocognitive assessment history from 3 rd parties- do not depend on person alone Review all the notes Often like peeling through the skins of an onion- multiple diagnoses Diagnosis is clinical since NO diagnostic tests Using standard rating scales PLUS developmental history PLUS observation PLUS family history à high level of diagnostic certainty between professionals AND predicting response to treatment

38 Experiences from Lothian Adult ADHD Clinic Treatment of graduates Have to prepare the individual: Using the risk factor model with the individual Learning the practical skills to live in the adult world Taking over personal responsibility for actions and managing behaviours Can often be resentful of diagnosis/ medication/ restrictions/ influence or control of parents Need additional non-drug help esp occupational/ educational life skills Consequences for driving/ work/ the future

39 Experiences from Lothian Adult ADHD Clinic Treatment of newly diagnosed Have to prepare the individual: Using the risk factor model with the individual Emotional impact of having the diagnosis (eg if only it had been recognised before.) Personal responsibility for actions and managing behaviours A range of responses from none to spectacular Response can be fast Patients/ partners may not like the change (eg no longer sparky ) Need additional non-drug help esp occupational/ educational life skills Consequences for driving/ work/ the future

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41 Conclusions ADHD traits do not disappear at 18 Being an adult = greater demands- ADHD traits can (but not always) hamper individuals from meeting these adult demands Adults with ADHD (both graduates and newly diagnosed) can gain benefit from 2y prevention treatment- closest to surgery in psychiatry ADHD as a risk factor, not a condition?

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