Adult ADHD How Big is the Problem? National Perspective

Adult ADHD How Big is the Problem? National Perspective East Midlands Mental Health Commissioning Network Conference March 23rd 2016 Professor Chris Hollis

Adult ADHD: National Perspective Adult ADHD: Key Facts Adult ADHD in AMHS Cost of untreated adult ADHD Mind the Gap - Transition to adult services Implementation of NICE CG72 8 years on Why adult ADHD is a wicked problem for AMHS? Adult ADHD service models

Adult ADHD: Key Facts Prevalence 2.5% (4.5k in East Midlands with severe ADHD) Two-thirds of young people with ADHD will have persisting symptoms and impairment in adult life Cost of untreated adult ADHD is 11k/person/yr ( 50M in EM) 25% of young male prisoners have ADHD Less than 20% of young people with ADHD successfully transition to adult mental health services Treatment: medication and behavioural management is highly cost-effective (NICE CG78) Co-morbidity is very common Depression, anxiety, ASD, tic disorder, SUD, personality disorder (ASPD, EUPD), bipolar disorder

Rates of ADHD within adult mental health services Odds ratio 11 10 9 8 7 6 5 4 3 2 1 0 1 10.4 4.8 2.4 0 5.16 4.64 6.12 Murphy et al., NIHR report, 2013; Deberdt et al., BMC Psychiatry, 2015;

The costs of untreated adult ADHD Daley, Jacobsen, Lange, Sorensen,& Walldorf, J. (2015). Explored the private and social costs of untreated ADHD in adulthood. 365 Adults with a diagnosis of ADHD and not other comorbid diagnosis were compared to same sex sibling without any diagnosed disorder

Yearly cost differences for public costs between ADHD adults and their siblings in euros Negative values represent a greater cost to individuals with ADHD

Yearly cost differences for public costs between ADHD adults and their siblings in euros Negative values represent a greater cost to individuals with ADHD

Yearly cost differences for private costs between ADHD adults and their siblings in euros Negative values represent a greater cost to individuals with ADHD

The cost of untreated ADHD in adults Total cost difference 13, 608 euros 11,000 per year/ person

The cost of untreated ADHD in adults East Midlands Est. 4500 cases 50M per year- Total Costs 10M in health & social care costs annually

Costs of untreated ADHD Increased accident rates = additional costs Increased crime rates = additional costs Higher suicides Higher mortality via accidents mainly Greater attendance at A&E Greater obesity Sleep problems Higher drug and alcohol use Higher development of anxiety, depression and personality disorder Most in primary care receiving alternative treatments (antidepressants, antipsychotics, counselling, CBT) Employment costs Educational costs

Percentage with criminal convictions Impact of adult ADHD on criminality Proportion of Swedish adults with criminal convictions over a 4-year period (Jan 1, 2006 to Dec 31, 2009) 40 35 30 25 36.6% ADHD General population 20 15 10 5 0 Men 8.9% 15.4% 2.2% Women Lichtenstein P, et al. N Engl J Med 2012;367:2006 14.

Medication for ADHD and criminality: Observational Swedish data base analysis Hazard Ratio for Conviction for Any Crime During ADHD Medication (2006 2009) vs. Non-Medication Periods Treatment Men (N=16,087) Hazard Ratio (95%CI) All medications 0.64 (0.60 0.68) Stimulants 0.66 (0.61 0.71) Non stimulant 0.76 (0.63 0.91) SSRI medication 1.04 (0.93 1.17) Crimes occurred less often during medication periods: - men 32% reduction - women 41% reduction Lichtenstein et al. N Engl J Med. 2012;367:2006-14.

Feedback from Prison Inspectorate Outside unbiased perspective Inspectors highlighted the CIAO project: All prisoners were offered screening for attention deficit hyperactivity disorder (ADHD) through the specialist Concerta (an ADHD treatment) in adult offenders (CIAO) trial Some prisoners on the CIAO programme to whom we spoke were experiencing some stability of behaviour for the first time in their lives. The HMIP report recommended continued support beyond the prison: There should be efforts to ensure the continued prescribing of medication and ongoing specialist support for prisoners started on the CIAO trial following their release Her Majesty s Inspectorate of Prisons report carried out in February of 2014 http://www.imb.org.uk/wp-content/uploads/2015/01/isis-2013.pdf Disclaimer: Equasym Depot is not approved for use in adults

All grown up and nowhere to go

CAMHS-AMH transition in ADHD Treatment Gap 0.04 Age CADDY Study data: McCarthy Hollis (2009) BJPsychiatry 194(3):273-7

ADHD Transitions Bridging the Divide

NICE CG72 on ADHD Recommendations: Transition arrangements for young people with ADHD into adult services Specialist multidisciplinary adult ADHD team responsible for: Diagnostic assessment and management for new and complex cases Consultation, training and advice for generic adult mental health teams and primary care Development of care pathways Development of shared care protocols

NICE Quality Standard (2013) Statement 2. Adults who present with symptoms of attention deficit hyperactivity disorder (ADHD), who do not have a childhood diagnosis of ADHD, are referred to an ADHD specialist for assessment. Statement 3. Adults who were diagnosed with and treated for attention deficit hyperactivity disorder (ADHD) as children or young people and present with symptoms of continuing ADHD are referred to general adult psychiatric services. NICE QS39 ADHD (2013)

National survey of 36 mental health trusts in England Less than half (43%) had a specialist adult ADHD service 50% reported that young people with ADHD were prematurely discharged because of lack of adult ADHD services Less than half had written transition protocols for ADHD

Why adult ADHD is a wicked problem for AMHS? A new clinical demand for already over stretched services Most adult psychiatrists (and AMH staff) are not trained to diagnose or treat ADHD ADHD falls below standard AMH thresholds Reluctance to prescribe stimulants ADHD is a chronic long-term neurodevelopmental condition doesn t fit acute/ short-term intervention model of AMHS

Adult ADHD Service Models Quality of assessment & treatment Tertiary AMHS Combined AMH-Tertiary High Variable High Waiting times Long Short Short (if commissioned service) Liaison with AMH Training of AMH staff Continuity of care Management of co-mobidities Weak N/A Good Little or none Little Good Difficult Good Good if AMH remain involved Variable (weak for SMI) Variable (weak for IDD) Good mix of disciplines Funding model Vulnerable Assured Assured if commissioned