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Specialist adult ADHD clinics in East Anglia: service evaluation and audit of NICE guideline compliance

  • Rakesh Kumar Magon (a1), Beena Latheesh (a2) and Ulrich Müller (a2) (a3)

Abstract

Aims and method

To measure compliance with National Institute for Health and Care Excellence (NICE) recommendations in two adult attention-deficit hyperactivity disorder (ADHD) clinics and to guide further service development. We audited the case notes of 150 patients referred to adult ADHD clinics in East Anglia in 2010–2011 against NICE standards using an adapted version of the ADHD audit support tool.

Results

We found good compliance with NICE standards for diagnosis, assessment and pharmacological treatment of adult ADHD. There was a failure in smooth transitional arrangements from child and adolescent mental health to adult ADHD services. Comprehensive treatment programmes addressing psychological, behavioural, educational and occupational needs were not well developed. Deficiencies were observed in conducting recommended physical examinations. Substance use was prevalent in almost half of ADHD patients.

Clinical implications

Greater attention is needed in delivering better transitional arrangements and comprehensive treatment programmes for adult ADHD. More structured training with emphasis on ADHD-specific psychological interventions, physical examination and treatment of complex cases, especially with comorbid substance misuse, should be offered to clinicians.

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Copyright

This is an open-access article published by the Royal College of Psychiatrists and distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Corresponding author

Correspondence to Rakesh Kumar Magon (rakesh.magon@hpft.nhs.uk)

Footnotes

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See invited commentary, pp. 140–3, this issue.

Declaration of interest

None.

Footnotes

References

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2 National Institute for Health and Clinical Excellence. Attention Deficit Hyperactivity Disorder: Diagnosis and Management of ADHD in Children, Young People and Adults (Clinical Guideline CG72). NICE, 2008.
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4 National Institute for Health and Clinical Excellence. CG72 Attention Deficit Hyperactivity Disorder (ADHD): Audit Support (Adults). NICE, 2008.
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7 Singh, SP, Paul, M, Islam, Z, Weaver, T, Kramer, T, McLaren, S, et al. Transition from CAMHS to Adult Mental Health Services (TRACK): A Study of Policies, Process and User and Carer Perspective (TRACK): Report for the National Institute for Health Research Service Delivery and Organisation Programme. NIHR, 2010. Available at http://www.nets.nihr.ac.uk/projects/hsdr/081613117 (accessed 3 Mar 2014).
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9 Solanto, MV. Cognitive-Behavioral Therapy for Adult ADHD: Targeting Executive Dysfunction. Guilford Press, 2011.
10 Nutt, DJ, Fone, K, Asherson, P, Bramble, D, Hill, P, Matthews, K, et al. Evidence-based guidelines for management of attention-deficit/hyperactivity disorder in adolescents in transition to adult services and in adults: recommendations from the British Association for Psychopharmacology. J Psychopharmacol 2007; 21: 1041.
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Specialist adult ADHD clinics in East Anglia: service evaluation and audit of NICE guideline compliance

  • Rakesh Kumar Magon (a1), Beena Latheesh (a2) and Ulrich Müller (a2) (a3)
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eLetters

Specialist adult ADHD clinics in East Anglia: service evaluation and audit of NICE guideline compliance

Laurence Jerome, Adjunct Professor of Psychiatry, Western University, London Ontario, CANADA.
28 June 2015

Magon, Latheesh and Muller's article is a useful practical addition to the literature (1). It details what clinicians working in the area of adult ADHD actually do in practice and how closely they follow recommended guidelines. It points to the difficulties of transition to the adult services with lack of resources and lack of clinical expertise for this population in the general adult services. This is a problem we also face in Canada.

The quoted prevalence of 10-20% of children with ADHD meeting diagnostic criteria for ADHD as adults may be misleading. Epidemiological studies from Dulcan and Kessler (2, 3) would suggest that between 65 to 85% of children with ADHD continue to manifest impairment as adults even if they do not meet full criteria for ADHD.

It would be helpful to know if UK clinics have access to long acting stimulants particularly lisdexamfetamine which appears to have less 'street value' given the comorbid substance use difficulties and the problems of diversion. The quoted prevalence of 7% of cannabis use seems low compared to the Canadian experience with ADHD adults.

References:

1. Magon RK, Latheesh B, Muller U. Specialist adult ADHD clinics in East Anglia: service evaluation and audit of NICE guidline compliance. BJPsych Bulletin 2015; 39,5,136-140.

2. Dulcan M. Practice parameters for the assessment and treatment of children, adolescents, and adults with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry 1997; 36(10 Suppl):85S-121S.

3. Kessler et al. The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. Am J Psychiatry 2006;163(4):716-23.
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Conflict of interest: None Declared

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Compliance with adult ADHD NICE guidelines in incarcerated populations

Pratish B Thakkar, Consultant Forensic Psychiatrist, Tees Esk and Wear Valley NHS Foundation Trust
Ipsita Ray, speciality doctor, Tees Esk and Wear Valley NHS Foundation Trust
Ayana Hazu, Medical Student, Newcastle University
28 June 2015

We read with great interest the article on the “Specialist adult ADHD clinics in East Anglia” (1). We conducted a similar audit in a young offender institution.

The Government’s policy for prison health is enshrined in the principle of ‘equivalence of care’ (2). Prisoners should receive the same level of health care as they would were they not in prison – equivalent in terms of policy, standards and delivery. It is our view that we should be delivering the same level of care to prisoners as is expected in the community.

A recent meta-analysis estimated the prevalence of ADHD in incarcerated populations as 26% based on diagnostic clinical interviews (3). It also concluded that compared with published general population prevalence, there is a fivefold increase in prevalence of ADHD in youth prison populations (30%) and a 10-fold increase in adult prison populations (26%).

We do not have a specialist clinic and the visiting psychiatrist provides the treatment. Our audit was conducted in a male young offender institution, which has 300 inmates. We screened the notes of all prisoners who were in the institution at the time of the audit. We found 20 prisoners had the diagnosis and 8 were on treatment.

Excellent compliance (100%) was observed in: readdressing the needs; assessment of comorbidities; measuring weight, BP and completing risk assessment for substance misuse. Good compliance was observed in: taking family history (75%); documenting the diagnostic criteria (65%) and obtaining information from community colleagues (65%). Treatment was initiated by a specialist in two thirds of the cases and monitored for side effects in half of them.

We have initiated an ‘ADHD pack’ for clinicians with relevant scales, leaflets for patients and adverse effects information. This will hopefully improve the compliance with NICE guidelines.

References:

1. Magon KM, Latheesh B, Müller U. Specialist adult ADHD clinics in East Anglia: service evaluation and audit of NICE guideline compliance. BJPsych Bull Jun 2015; 39 (3) 136-140.

2. Health Advisory Committee for the Prison Service (1997). The Provision of Mental Health Care in Prisons. London: Prison Service.

3. Young S, Moss D, Sedgwick O et al. A meta-analysis of the prevalence of attention deficit hyperactivity disorder in incarcerated populations. Psychological Medicine 2015; 45: 247-258.

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Conflict of interest: None Declared

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