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

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

3. Core symptoms of ADHD
Inattention
Hyperactivity
Impulsivity

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

5. 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

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

7. 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

8. 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.

9. 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)

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

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

17. 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

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

19. 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

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

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

22. Drug treatment of ADHD Side effects Headache Insomnia Reduced appetite
Anxiety

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

24. Obstacles to treatment
Cumulative referrals & assessments (Wirral)

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

26. 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].

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

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

29. 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

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

31. 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

32. 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?”

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

34. Any questions?