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20180904 Flynn ADHD supplement v4

Recognising and managing adult ADHD in primary care 

Dr Kuben Naidoo FRCPsych, Consultant Adult Psychiatrist, Mersey Care NHS Trust, and Chair of the ADHD Foundation

 

 

 

 

 

 

 

Key messages

  • If the symptoms of ADHD are adversely affecting everyday life, it is strongly advised to refer the individual to a specialist to confirm the diagnosis and initiate treatment

  • NICE recommends either methylphenidate or lisdexamfetamine as first-line medication for the treatment of ADHD in adults

  • Modified-release preparations are favoured due to improved adherence and their pharmacokinetic profiles. Specify the brand to be prescribed as the different modified‑release preparations may not have the same clinical effect

  • Blood pressure and heart rate need to be monitored before and after every dose titration and every 6 months

  • No routine blood tests or electrocardiograms are required unless clinically indicated

  • A shared care agreement provides primary care with the information needed to support the ongoing prescribing of medication for the adult ADHD patient

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental condition characterised by inattention, hyperactivity, and impulsivity.1 Approximately 3–4% of adults in the UK have ADHD.2 An estimated 46–66% of children with the disorder continue to experience symptoms in adulthood.3

Optimal outcomes can be achieved for adults with ADHD if healthcare professionals in primary care are not only able to recognise adult ADHD but are also familiar with how it is treated and managed within the NHS.

Recognition in primary care

Symptoms of ADHD in an adult may be first identified by the affected individual, a close relative, work colleague, or college lecturer. The ADHD diagnostic criteria used by clinicians broadly follow the criteria outlined by the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5)1 (Box 1) and the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10).4 Individuals may present to their GP with some of these symptoms. Key to making the diagnosis is identification of the degree of impairment ADHD has in social, occupational, academic, and interpersonal settings.5

Referral to specialist services

It is strongly advised to refer an individual with adult ADHD to an ADHD specialist if the symptoms are adversely affecting life at home, college, work, and/or social time.5 Pathways to specialist services, as well as resourcing for ADHD, vary from region to region.

A brief discussion with the primary care mental health liaison team or local community mental health team will ensure an individual with ADHD is referred to the appropriate ADHD service or specialist. The use of an integrated care pathway may help to improve the quality of referral and aid in the overall assessment.

It is useful for the ADHD specialist to have the following information:

  • family history (there is a strong pattern of heritability)6
  • patient or family history of heart disease5
  • mental health history (anxiety disorders are a common comorbidity)7
  • any history of alcohol or other substance misuse5 (substance abuse does not exclude treatment for ADHD but does influence the specialist’s decision on an appropriate management plan)
  • past school reports—these are an excellent source of information and offer an opportunity to ‘see the patient as a child’
  • collateral information from a parent, partner, or sibling may offer insights into the patient’s daily activities and ability to live normally.

NICE-recommended treatment options

The NICE Guideline 87 published in March 2018 provides a detailed outline of the treatment options for adults diagnosed with ADHD.5 NICE recommends stimulant medication, either lisdexamfetamine or methylphenidate, as first‑line medication choices.5

Modified-release preparations are favoured for treatment of ADHD because of their convenience, potential for improved adherence, reduction in the risk of diversion, and for their pharmacokinetic profiles (the varying immediate-release and modified-release components of each preparation).5 Not all modified-release preparations are the same and the choice of preparation should be tailored to personal circumstances, taking into consideration academic, occupational, and lifestyle requirements.5 Licensing for each preparation varies and not all are licensed for the treatment of ADHD in adults.5 This is particularly important when considering initiation of medication.

Medication for adult ADHD is broadly divided into the stimulant and non-stimulant groups. The latter includes atomoxetine, which may be considered in patients who have previously tried but are unable to tolerate stimulants.5

No routine blood tests or electrocardiograms are required unless there is a clinical indication.5 Blood pressure and heart rate need to be monitored before and after every dose titration and every 6 months.5

Some adults with ADHD may choose to decline medication, in which case psychological therapy should be offered—cognitive behavioural therapy may be beneficial.5

A shared care agreement supports ongoing prescribing of medication

Following titration and a period of maintenance on the medication (which may take 3–6 months to achieve), the specialist may decide to transfer a patient to their primary care team under a shared care agreement or protocol.5

The shared care agreement or protocol provides the GP with information to support the ongoing prescribing of medication for the patient, and also defines the routes to access specialist support directly should there be any concerns about the patient. Concerns that may arise and require specialist review include treatment-related side-effects and breakthrough symptoms.

Specialists should provide a full explanation of the diagnosis and rationale behind any therapy initiated. It is important that the GP understands the requirements for, and feels comfortable with, taking over the role of prescribing.

Box 1: ADHD diagnostic criteria1

Inattention

  1. Inattention to detail at work or making careless mistakes
  2. Difficulty sustaining attention
  3. Does not seem to listen when spoken to directly
  4. Does not follow through on instructions
  5. Difficulty organising and prioritising tasks
  6. Reluctant to engage in tasks that require sustained mental effort
  7. Easily distracted
  8. Forgetful in daily activities e.g. appointments or paying bills
  9. Often loses things e.g. keys, purse, cards or phone.

Hyperactivity and impulsivity

  1. Often fidgety
  2. Struggles to sit still
  3. Feels restless all the time
  4. Unable to engage in leisure activities quietly
  5. On the go all the time
  6. Talks excessively
  7. Tendency to blurt things out
  8. Difficulty waiting in line
  9. Often interrupts or intrudes on others.

ADHD=attention deficit hyperactivity disorder

Collaboration and effective communication between primary and secondary care services can minimise the impact of adult ADHD on patients, their families, friends, and colleagues, and assure adults with ADHD of the continuity of care required to address their needs.

Conflicts of interest

Dr Naidoo received remuneration from Flynn Pharma Ltd for writing this article, has carried out advisor and speaker engagements for Shire, Janssen, Otsuka, Lilly, Lundbeck and AstraZeneca, and has received educational grants from Janssen, Lilly, Lundbeck, Otsuka, Shire, and Sunovion.

References

  1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington, VA: APA, 2013.
  2. NICE. Attention deficit hyperactivity disorder: background information. NICE, 2018. Available at: https://cks.nice.org.uk/attention-deficit-hyperactivity-disorder#!backgroundsub:2 (accessed 13 August 2018).
  3. Barkley R, Fischer M, Smallish L et al. J Abnorm Psychol 2002; 111: 279–289.
  4. Behavioural and emotional disorders with onset usually occurring in childhood and adolescence (F90-F98). In: WHO. International statistical classification of diseases and related health problems. 10th revision. Available at: http://apps.who.int/classifications/icd10/browse/2010/en#/F90-F98 (accessed 19 July 2018).
  5. NICE. Attention deficit hyperactivity disorder: diagnosis and management. NICE Guideline 87. NICE, 2018. Available at: www.nice.org.uk/guidance/ng87 (accessed 19 July 2018).
  6. Royal College of Psychiatrists. Attention deficit hyperactivity disorder (ADHD) in adults. Available at: www.rcpsych.ac.uk/healthadvice/problemsdisorders/adhdinadults.aspx (accessed 19 July 2018).
  7. Pliszka S. J Clin Psych 1998; 59 (Suppl 7): 50–58.

Job code: UK/MXL/0918/0109a

Date of preparation: November 2018