ADHD in Primary Care Peter Mason Consultant Psychiatrist Adult ADHD Service Cheshire & Wirral Partnership NHS Foundation Trust

A show of hands Yes No Don’t know Is attention deficit hyperactivity disorder (ADHD) a legitimate diagnosis? Yes No Don’t know

Core symptoms of ADHD Inattention Hyperactivity Impulsivity

Inattention Distractible Difficulty maintaining attention / concentrating Not listening when spoken to Difficulty organising / following instructions Avoiding activities involving mental effort Forgetful

Hyperactivity symptoms Fidgety Getting up from seat when should be seated Running about when should be still Noisy doing leisure activities Often ‘on the go’ or acts as if ‘driven by a motor’ Talking excessively

Impulsivity Interrupting or intruding on others Blurting out answers to questions Trouble waiting in turn Risk taking Spending Fighting

Diagnostic Criteria (DSM-V) Inattention Lack of attention to details / careless mistakes Difficulty sustaining attention Does not seem to listen Does not follow through on instructions Difficulty organizing tasks and activities Avoids sustained mental effort Loses & misplaces objects Easily distracted Forgetful in daily activities 6 or more of each symptom if < 17 5 or more of each symptom if > 17 Hyperactivity / Impulsivity Fidgetiness (hands or feet) / squirming in seat Restless during activities Running about / feeling restless Excessively loud or noisy Always "on the go” Talks excessively Blurts out answers Difficulty waiting his or her turn Tends to act without thinking Often impatient Uncomfortable doing things slowly or systematically Difficult to resist temptations or opportunities

Associations with ADHD Mortality: Mortality 5.85 per 10,000 person-years for individuals with ADHD compared with 2.21 in those without ADHD (adjusted MRR 2.07; 95% CI 1.70‒2.50; p<0.0001) Dalsgaard et al. (2015) While ADHD-like symptoms are found in many people some of the time, in people with ADHD they are severe, persistent over time and lead to clinically significant impairments.

Associations with ADHD Education Adults with ADHD significantly less likely to have obtained a (US) college degree than those without ADHD1 26% vs 19%; p<0.01 Employment Adults with ADHD significantly less likely to be in work than those without ADHD2 24.3% vs 78.8%; p<0.001 1. Biederman et al. 2008, 2. Halmoy et al. 2009 500 with self reported ADHD vs 501 without. US study 414 adults with ADHD vs 357 controls. Norway (32% disability pension, 20.6% vocational rehab)

Associations with ADHD Crime 30 -45% young offenders (in prison) At least 26% adult prisoners (strict criteria) 4-5x greater chance of arrest Multiple arrests Younger onset of offending High rate of recidivism Young et al. 2011a, 2011b & 2014

Associations with ADHD Driving 4 x more likely to crash 7 x more likely to have 2 or more incidents 4 x more likely to be at fault Barkley et al. 2009, Lichtenstein et al. 2012, Torgerson et al. 2006

Associations with ADHD Psychiatric comorbidity 66% of adults with ADHD have at least one comorbid psychiatric disorder Mean number of comorbidities per adult with ADHD is 2.4 Most prevalent comorbid conditions: substance-use disorders: 40% anxiety disorders: 23% mood disorders: 19% Piñeiro-Dieguez B et al. 2016

Associations with ADHD in students   ADHD No ADHD At least one comorbid psychiatric disorder 55% 11% 2 or more comorbid psychiatric disorders 32% 4% Depressive disorder 5% Anxiety disorder 29% First-year college students aged 18‒22 years with (n=220) and without (n=223) ADHD USA Anastopoulos et al. 2016

Benefits of treating ADHD 100 80 60 40 20 Driving Obesity Self-esteem Social function Academic Drug/addictive Antisocial Services use Occupation No benefit Benefit Systematic review of 48 studies Shaw et al. 2012

Drug treatment of ADHD Methylphenidate Ritalin - unlicensed in adults, >18 Equasym XL - unlicensed in adults, >18 Concerta XL - unlicensed in adults, >18* Medikinet XL - licensed in children & adults Block Dopamine and Noradrenaline Reuptake Transporters *can be continued from adolescence into adulthood

How does it all work? Dopamine Transporter Post synaptic receptor Presynaptic vesicle Dopamine

Drug treatment of ADHD Amphetamines Dexamfetamine (unlicensed in adults, >18) Lisdexamfetamine (licensed in children & adults) Block Dopamine and Noradrenaline Reuptake Transporters & discharge Dopamine from presynaptic vesicles

How does it all work? Dopamine Transporter Post synaptic receptor Presynaptic vesicle Dopamine

Drug treatment of ADHD Non-stimulants Atomoxetine (licensed in children & adults) A Noradrenergic reuptake blocker, ?increase SNAP 25 Guanfacine (unlicensed in adults, >18) A selective α2A receptor agonist

How does it all work? Noradrenaline Transporter Post synaptic receptor Presynaptic vesicle NA & Dopamine

How does it all work? Noradrenaline Transporter Post synaptic receptor Guanfacine Presynaptic vesicle NA & Dopamine

Drug treatment of ADHD Side effects Headache Insomnia Reduced appetite Anxiety

Obstacles to treatment Demand outstrips capacity (waiting lists) Prescribing guidelines & shared care GP workload Expertise in primary care Fragmented NHS

Obstacles to treatment Cumulative referrals & assessments (Wirral)

Obstacles to treatment Demand outstrips capacity (waiting lists) Prescribing guidelines & shared care GP workload Expertise in primary care Fragmented NHS

Prescribing guidelines NICE: All medication for ADHD should only be initiated by a healthcare professional with training and expertise in diagnosing and managing ADHD. A healthcare professional with training and expertise in managing ADHD should review ADHD medication at least once a year. GMMMG The patient will not be discharged from out-patient follow-up while taking [insert text here].

Obstacles to treatment Demand outstrips capacity (waiting lists) Prescribing guidelines & shared care GP workload Expertise in primary care Fragmented NHS

New integrated model Consultant psychiatrist & specialist nurse prescriber Specialist nurse prescriber General Practitioner

Primary care based clinics 4 hubs Each hub has an ADHD specialist nurse prescriber for 1 day a week Next door is GP ADHD specialist for the morning Every fourth week consultant and third sector join the clinic for the full day Access to EMIS Reception staff training

GP Training Training manual developed with Shire Training based around case based discussions of increasing complexity Clinic based training On site supervision / support

Primary care based clinics Progress Training completed by May 2018 GP led clinics began in 2 hubs March 2018 Next 2 hubs go live mid August Discharges to primary care increased New assessments increased Snags IT problems Initial attendance Indemnity

GP Feedback “Didn’t realise ADHD was so easy” “Enjoy being able to spend an adequate amount of time with patients” “I now understand why X’s anxiety didn’t get better” “When can I start diagnosing and treating?”

Patient feedback Too early to say Mixed feedback so far: Some disasters: wrong venue, wrong letter Some successes: patient with “epilepsy”, better venue

Any questions?