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 Lead, UK Adult ADHD Network (UKAAN)
Disclosures Speakers and Consultancy fees from Lundbeck Janssen Eli Lilly
Breif Introduction Epidemiology Clinical Presentation Co-morbidities & Consequences Implications of Untreated ADHD Treatment Service Development
Introduction-1 ADHD (Hyperkinetic Disorder) is a clinical Syndrome characterised by high levels of hyperactive, impulsive and inattentive behaviours often in early childhood - that persist over time, pervade across situations and lead to notable impairments. Although traditionally considered as a childhood disorder, adults with ADHD features are increasingly presenting for evaluation and treatment.
Introduction-2 The Mental Health Act (1983), through its recent amendments, considers ADHD as mental disorder. The National Institute for Clinical Excellence (NICE) recognises that signs of ADHD may persist into adulthood with associated emotional and social problems.
Epidemiology-1 Follow up studies of children with ADHD find that 15% still have the full diagnosis at 25 years, and a further 50% are in partial remission, with some symptoms associated with clinical and psychosocial impairments persisting (Faraone SV, Biederman J, Mick E. The age-dependent decline of attention deficit hyperactivity disorder: a meta-analysis of follow-up studies. Psychol Med 2006; 36:159-65.)
Epidemiology-2 Research suggests that 4-5% of adult population may have ADHD (Beiderman J, Faraone S, Mick E, Age dependant decline of ADHD symptoms revisited: impact of remission definition and symptom subtype. Am J Psychiatry 2000; 157(5): 816-817.) Recent studies indicate that the pooled prevalence of adult ADHD was 2.5% (95% CI 2.1 3.1) (Prevalence and correlates of adult attention-deficit hyperactivity disorder: metaanalysis Viktória Simon, Pál Czobor, Sára Bálint, Ágnes Mészáros, István Bitter. The British Journal of Psychiatry Feb 2009, 194 (3) 204-211; DOI: 10.1192/bjp.bp.107.048827)
Epidemiology-3 The Black Country has a population of approximately 1.1million people of which around 640,000 are adults. Statistics indicate that there will be approximately 19-32,000 adults within the catchment area who may have features of ADHD (for comparison, there are only around 6,400 people with schizophrenia).
Clinical Presentation-1 Inattention Hyperactivity Impulsivity
Clinical Presentation-2 Inattention lack of attention to details or makes careless errors.. difficulty sustaining attention in tasks.. does not seem to listen fails to follow through finish difficulty organising tasks avoids/dislikes tasks requiring sustained mental effort loses things easily distracted forgetful
Clinical Presentation-3 Hyperactivity fidgety leaves seat runs/climbs difficulty playing quietly on the go talks excessively
Clinical Presentation-4 Impulsivity blurts out answers difficulty awaiting turn interrupts/intrudes on
Co-morbidities & Consequences-1 85% : one 60% : two or more Depression 19-37% Anxiety disorders 25-50% Alcohol misuse 32-53% Substance misuse 08-32% Personality disorders 10-20% Antisocial Behaviour 18-28% Autistic spectrum 10% Learning disability 15-25%
Co-morbidities & Consequences-2 Consequences Poor self-esteem/low confidence Poor social skills Relationship difficulties Low frustration tolerance Difficulties with -planning -organising/structuring -time management Anger control
Implications of Untreated ADHD-1 Schooling: suspensions 60% -Barkley et al 2006 drop outs 32% excluded x 11 lower status jobs/multiple changes -Mannuzza et al 1997 Reduced productivity -Noe & Hankin et al 2001 Higher rates of anti-social personality Higher rates of substance-misuse -Biederman et al 1998
Implications of Untreated ADHD-2 Injuries: x 3-4 (1.2m deaths/yr) -Stewart et al 1966, Mitchell et al 1987 Higher attendance @ GP/A & E - Lepson et al 2001 Driving violations/accidents x 4 -Barkley et al 1996 Crime: prison population - 9-45% Families: parental frustration Marital discord -Barkley et al 1990 Divorce/separation x 3-5 -Brown et al 1989 Loss of working days/productivity -Noe & Hankin 2001 Early parenthood -Barkley 2006
Treatment-1 Psycho-education Preparation (Re)-training/ADHD Coaching Pharmacological Rx Family therapy Psychological Mindfulness, CBT, Anger management, Self Esteem Support groups
Treatment-2 Pharmacological Stimulants -methylphenidate -dexamfetamine Non-stimulants -atomoxetine
Service Development-1 Whilst services for children are commissioned as a part of core CAMHS, there remains a commissioning gap for adults.
Service Development-2 There has been growing scientific evidence that adults with ADHD respond well to psychopharmacological interventions (Spencer TJ. ADHD Treatment across the life cycle. Journal of Clinical Psychiatry 2004; 65 suppl 3 22-26.) NICE guidelines recommend pharmacological interventions as the first line of treatment in adults with ADHD
Service Development-3 Adult Neurodevelopmental Service This is a national service and we welcome enquiries from a range of agencies. To refer an individual to either service we require a referral. Funding will need to be agreed by the relevant Clinical Commissioning Group before any work is undertaken, evidence of which should accompany the referral ASD Assessment Service We provide an Autism Spectrum Disorder assessment and diagnostic service for adults, using the latest assessment and diagnostic tools We accept referrals for individuals aged 16 and older. Please note we do not accept them for individuals, diagnosed with moderate to severe learning difficulties Referrals are accepted from a range of agencies. Typically referrals come from GPs; local authorities; other NHS providers or Clinical Commissioning Groups We do not manage any co-morbid conditions which should be managed by local adult psychiatric services.
Service Development-4 Adult Neurodevelopmental Service ADHD Assessment and Treatment We offer assessment and advice pharmacological treatments for patients suspected of or having a diagnosis of ADHD. This will be done through a shared care protocol with the patients GP. We accept referrals for individuals aged 16 and older. Please note we do not accept them for individuals, diagnosed with moderate to severe learning difficulties. Referrals are accepted from a range of agencies. Typically referrals come from GPs; local authorities; other NHS providers or Clinical Commissioning Groups. Funding must be agreed by the relevant CCG before any work is undertaken. We do not manage any co-morbid conditions which should be managed by local adult psychiatric services. We do not at this stage offer psycho-social intervention or support. CAMHS Transition???
Service Development-5 Patients seeking ASD assessment and diagnosis We offer 2 x 90 or 3 x 60 minutes sessions of one of our Consultant Psychiatrists who, following assessment will provide a comprehensive report along with recommendations for accessing further support History taking, mental state examination, risk assessment Interview the family, school reports, info from family, friends, employer Structured & Validated ASD assessment tools Where appropriate, we can also offer a further assessment by one of our Psychologists in complex cases
Service Development-6 Patients seeking ADHD assessment and treatment Baseline Blood Investigation & ECG - GP 2 x 90 or 3 x 60 minutes assessments by one of the lead consultant psychiatrists History taking, mental state examination, risk assessment Interview the family, school reports, info from family, friends, employer DIVA-2,, Wender Utah Scale, ASRS, Quality of Life Assessment as required Final report sent to the GP with a copy to the patient
Service Development-7 Patients seeking ADHD assessment and treatment- Contd. Up to 4 appointments for initiation and dose optimisation of medications -30 minutes each The above managed through a shared care protocol Annual Reviews One Hour
Service Development-8 Fees ASD ASD assessment and diagnosis 675 ADHD new patient ADHD new patient assessment 675 ADHD follow-up medication advice 204 per appointment Annual review for diagnosed and stable 285.40 patients ADHD - patient already diagnosed First appointment 448.59 ADHD follow-up medication advice if required (up to 5 appointments) 163.19 Annual review for diagnosed and stable patients per appointment 285.40