Adult ADHD Service - 5 BP. Dr Joe Johnson Consultant Psychiatrist Five Boroughs Partnership NHS Trust

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1 Adult ADHD Service - 5 BP Dr Joe Johnson Consultant Psychiatrist Five Boroughs Partnership NHS Trust

2 My Background Consultant Psychiatrist in 5BP since 2005 Working both in Community and Prison MH (Risley) Lead Clinician of Adult ADHD service in Wigan since 2010 Leading the Trust wide Adult ADHD service since December 2012 but...i don t claim to be an expert

3 Use of stimulants leads to abuse and addiction Its normal. We all have these symptoms. Why the diagnosis? They just need to try harder.

4 Case History 21 year old man, Risley prison Seen in segregation unit - following serious DSH Childhood diagnosis of ADHD (from age 8) Taken off ADHD meds when 16 Self medicating with illicit drugs Extensive contact with Criminal Justice system Treated with antipsychotics, antidepressants and sleeping tablets Distressed mum told Prison is not commissioned to treat ADHD

5 Case history Commenced on ADHD meds [Concerta XL] Weaned off all other medications Marked reduction in hyperactivity, impulsivity Moved to main wing Now working as a wing cleaner Engaging in education (not disruptive in class) Due for release in 2 months, but No ADHD Service in his local area ADHD now commissioned in prison on a cost per case basis

6 Prevalence of prescribing ADHD drugs in patients aged years ( ) - The British Journal of Psychiatry, February 2009

7 Untreated ADHD Associated with several negative outcomes in adulthood including: poor rates of employment harm to relationships with family and friends increased rates of criminality and accidents the development of comorbid psychiatric symptoms including anxiety, depression and substance misuse Premature cessation of medications during adolescence is likely to impair function at a crucial developmental stage.

8 Co-morbidity in ADHD Mood disorders Depression, Rapid cycling MD Anxiety Disorders OCD Conduct Disorder/ODD Personality Disorder EUPD, Antisocial PD Substance Misuse Psychosis

9 Depression: Depression in ADHD: 55% ADHD in Depression: 20% Anxiety Disorders: Anxiety disorders in ADHD: 25-63% ADHD in Anxiety Disorders: 17% Bipolar I/II: Bipolar I/II in ADHD: 10% ADHD in Bipolar I/II: 18% Borderline Personality Disorder: ASD: BPD in ADHD: 15-40% ADHD in BPD: 20% ASD in ADHD: 20% ADHD in ASD: 40% ADHD and Comorbidity Kan, C. 2013

10 Prevalence of ADHD in an adult outpatient clinic in UK 194 patients approached: 59 refused, 11 excluded 124 remaining patients aged years 57 male/67 female ASRS and Wender Utah Rating Scale Diagnosis of ADHD was made in 22% (n=27: 12 male, 15 female) Clinic diagnosis before assessment Number (n = 124) Depression 59 Bipolar/schizoaffective/psychosis 48 Neurosis and stress 12 Personality disorder 5 Rao, Place. Prog Neuro Psyc 2011;15(5):7 11.

11 Outcomes and mortality rates in adults diagnosed with ADHD in childhood (age years) Rochester (USA) Birth Cohort /5718 children with identified ADHD (mean age 10 years) prospectively assessed in adulthood Data available and use permitted by 232 patients (mean age 27 years) ADHD persists into adulthood: 29.3% SMR for suicide versus controls: 4.83 SMR for accidents versus controls: 1.70 Conclusions Childhood ADHD has significant risk for mortality, persistence of ADHD, and long-term morbidity in adulthood Adults with ADHD are at increased risk of death from suicide SMR: standardised mortality ratio. Barbaresi et al. Pediatrics 2013;131:

12 Adult ADHD Service at 5BP No adult ADHD service at all until 2009 Few private referrals to Maudsley (London), Priory (Manchester) Pilot in one of the 5 boroughs in 2009 Other 4 boroughs commissioned on a cost per case basis (2010 to 2016) Referral pathways reviewed now accepting direct referrals from primary care.

13 What helped? Awareness of ADHD as a D/D Awareness of service Training events Working with local CJLT/Probation service Referral numbers Service evaluation Audit Working closely with stakeholders

14 Sources of referrals Transition - CAMHS/Paeds GP Mental Health Teams Assessment Team, Liaison, EIT CJLT/Substance misuse services

15 Current situation Bid to expand the service Qb test Meeting Commissioners Develop Business case Shared care guidance for prescribing

16 Challenges at 5BP Prescribing (off license) Different commissioning arrangements Rapidly growing waiting lists Waiting times increasing (up to 18 months from the time of referral) Staffing levels High DNA rates Co-morbidities, who treats them? Risky client group Higher rates of SUIs

17 Future models Should CMHTs manage less complex patients? Should stable patients be discharged back to primary care? (current practice annual review) GPSI model Neuro-developmental service for ADHD, ASD, Dyslexia

18 North East Manchester Sector

19 LANC Independent sector Over 20 years ADHD/ASD across the lifespan Multi-disciplinary team

20 Service Details Locations in bury, rochdale and oldham Clinical psychologist, consultant psychiatrist, adhd specialist nurse, asd specialist practitioner, ADHD/ASD Coach, Speech and language therapist, occupational therapist. At least fortnightly clinics in each location

21 Service Details links with other services - adult mental health, camhs Transition pathway support

22 Referrals Screening questionnaires to help identify appropriate referrals.

23 dr. neil rutterford, director